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Y r APPLICATION FOR PERMIT 36 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 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. ©O Job Address %'7 Cit Lot Size PM �� Owner's Name 'Address Phone ContractorA ss 6 ense No. Phone� v! TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cl PUMP INSTALLATION ❑ SYSTEM REPAIR LJ 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i M Public F Other ❑ Delta Depth of Grout Seal Type of Grout__. _ I I Irrigation —_-Approx. Depth i I Eastern Surface Seal installed by Repair Work Done ❑ Type of Pump H.P, State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial- Other 019 W Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: r table depth r I# SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ / j5 Method of Disposal ZDistance to nearest: Well Foundation operty'Line LEACHING LINE ❑ No. & Length of lines � 0 Total length/sim FILTER BED ❑ Distance to nearest: Well L_r>t_cam_ Foundation ;4142 Property Line Z riP ple7 JJJI SEEPAGE PITS I I Depth f/ i Number p J SUMPS ❑ Distance to nearest: Well 6149 Foundation © Property Line - C DISPOSAL PONDS ❑ I hereby certify that I 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 District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." r The applicant must II for all requil inspection mplete drawing on re r e std , Signed X Title: — ( � Date: 71 FOR DEPARTMENT USE ONLY r Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection byDate Additional Comments: ^ T' ❑ Silk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE _ INFO yArMODUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERM17'NO. +.EH13-24SREV.tin51 •`YJ alt ss �•- -ryv 00 EH 14-28 I V .r`)r a