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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1 1601,E. HAZELTON AVE., STOCKTON, CA 0 Telephone .(209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . c 3 E.a'w .f 1, (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. 1861 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. it Job Address i .'k."r City. b Lot Size Z��x>�g PM Owner's Name _. Address ,7T3 d4 ,�� 7 /�� Phone Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑* 3 DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0.� R ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES OSAL FLD. PROP. LINE FOUNDATION AGRICULTUR OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBL CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom - Manteca Dia.-of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel P ❑ Tracy Type of Casing ' Specifications N 0 Public �COJType' or ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation pprox. Depth C1 Eastern Surface Seal Installed by V . Repair Work e f Pump H.P. State Work Done Well ruction ❑ Well!Diameter Sealing Material Itop 50'1 l Depth % Filter Material IBelow 501 l TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is j; available within 200 feet.) 1 Installation will serve: Residence Commercial_ Other ' Number of living units: I� Number of bedrooms Character of soil to a depth of 3 feet: —Q* table depth 11 SEPTIC TANK Type/Mfg Capacity No.)Compartments �f�1 PKG. TREATMENT PLT. F] I! Method of Disposal ��1p n Distance to nearest: Well Foundation Property Line I.` I LEACHING LINE ❑ No. & Length of lines Total length/size r FILTER BED ❑ Distance to nearest: Well Foundation Property Line (� r V ) SEEPAGE PITS ❑ Depth Size Number ✓} SUMPS ❑ Distance to nearest:..4 Well Foundation Property Line l DISPOSAL PONDS ❑ 46 1 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 Sari 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, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all require inspecti s. Complete drawing on reverse side, Signed • Title: Date: O FO�R DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by 9 bated Additional Comments: ❑ Stk 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 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED 6Y DATE PERMIT NO. INFO CASH + EH 13-24 IREV.i/e 5t EH 1428 f '� j