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y.. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED--- (Complete in Triplicate) I 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. i Job Addres ✓ City f Lot Size f M Owner's Name u._-� Addres � Phone Contractor ifr Address F r ✓ ' -- ` L`ic-ense Oa5!Y3 Phone TYPE OF WELL/PUMP: I` NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ "" SYSTEM REPAIR'D OTHER ❑ DISTANCE TO NEAR EST,.SEPTIC TANK_ SEWER LINES DISPOSAL FLO. 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 1 1-1 Public ❑ Other CZ Delta Depth of Grout Seal " Type of Grout I.1 Irrigation _I(Approx, Depth (.1 Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H,P. - State Work Done _ (� Well Destruction ❑ Well Diameter Sealing Material Itop 501- ` ' Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION i I DESTRUCTION ! I (No septic system permitted if public sewer is - available within 200 feet.l Installation will serve: Residi`ence_ Commercial Other Number of living units: y� Number of be ooms ,I Character of soll to a depth of 3'feet: �'� "�Q Water table depth b SEPTIC TANK F' Type/Mfg Capacity L1Q No. Compartments 17— PKG. 7 -+PKG. TREATMENT PLT. ❑ i� } r# r Method of Disposal 11f-' O000istance to nearest: Well Foundation _� Property Line "ff LEACHING LINEe No. & g hf Len -lines'. •.: ! Total length/size FILTER er- FILTER BED ❑ _D``Distance to nearest: Well Foundation'` Property Line SEEPAGE PITS 1 Depth %� Size_ _ Number ''-SUMPS Cl Distance to nearest: Well FouWdation,_ r�rf- _ Property Line DISPOSAL PONDS ❑ e 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 agents 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,I shall employ persons subject to workman's compensa- tion.laws of California." d - The applicant-must call for all requir inspections. Complete drawing ori reverse side. ' Signed X Title: _ Date FOR DEPARTMENT USE ONLY Application Accepted by Date r v o Area Pit or Grout Inspection by ( :i � J�t DateFinal Inspection by Date Additional Comments:, �1 � C�✓� � T�,,, ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 623-7104 0 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 FEE INFO AM06NT DUE AMOUNT REMITEDTCASHCK RECEIVED BY DATE PERMIT'NO. '+ III.Lr �r/� EN 13-24(REV.i i H sl 7 Q EN 14-26 II Jam— V