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=I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL.HEALTH DISTRICT 1601 E. HAZES LTON AVE., STOCKTON, CA Telephohe (209) 466-6781 PERMIT EXPIRES 'I'YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described, This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. ( j Job Address ` S City L[� Lot Size lar-la—sl PM Address Owner's Name �r`il�f' SQ f� 7 ' Phone V �� >3 7 i Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t� ❑ Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1`1 Public ❑ Other , ❑ Delta Depth of Grout Seal Type of Grout I Irrigation -.-Approx. Depth i I Eastern Surface Seal Installed by Repair Work Done Ll Type of Pump H.P. State WJ Doe _ ell Destruction C Well Diameter-_ Sealing Material (top 50') 4 Depth Filler Material {Below 50') _ TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is available within 200#eet.) �, ' Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: --^^ Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ A. Method of Disposal Distance to nearest: Well Foundation Property Line r` LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line a DISPOSAL PONDS ' ❑, i r- I hereby certify that.[ have prepared this application and that the work will be done in accordance with San Joaquin county ordinances.,-state laws, and rules and regulations of the San Joaquin Local Health Diktrict. Home owner or licensed agent's signature certifies the following: "I certify that in the perforrnarice of the work for which this permit is issued, I shall not employ a'ny-person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the fo]lowing:"I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion lawsof lifornia." The applican ust c or all reed in ctions. Complete drawing on reverse side. f E Signed X -Title: Date: + I�~ -JL/ FOR DEPARTMENT USE ONLY �1 Application Accepted by Date �rQ �! 0 Area Pit or Grout Inspection by ate Final Inspection by Date d r Additional Comments: e�/ / fD 2 D ❑ Stk 466-6781 ❑ Lodi 369 1 Manteca 823-7 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO �7AM�OUNT DUE AMOUNT REMITTED ///CAS RECEIVEl1 BY / HAf/TE [},,� ?/��E77TRMI7 NO�.p +.EH 13-24(REV.1ik51 \ [Uo //j