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APPLICATION FOR PERMIT C7— SAN JOAQUIN LOCAL HEALTH DiSTRIC�—V 1601 E. HAZELTON AVE., STOCKTON;=Telephone (209) �'PERMIT EXPIRES 1-YEAR FROM DA1,E ISSUED ----- (Complete (Complete in Triplica+e). 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. � 4 Jab Address {{ —City Lot Size PM Owner's Name y- _�_C�.1b_ Address + Phone 4 U(o 5 7 Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUM STALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TA SEWER LINES DISPOSAL FLD'�- - 'PROP:LINE FOUNDATION AGRICULTU ELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL P LE A CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ nt Dia. of Well Excavation Dia. of Well Casing CI Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing C1 1 Public 171 Other Specifications f 1 Dolt. epth of Grout Seal Type of Grout I I Irrigation — rox. Depth I I Eastern Su Seal Installed by L! Repair Work Done ❑ Ty of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') `-+TYPE-O"EV-4 WORK: ._NEW_INkALLATL!RN I.1 REPAIR/ADDITION l 1 DESTRUCTION r --z-----� INo septic system permitted if public sewer is , iAabl.-wilhirt 200 fact.) Installation will serve: Residence_ Commercial_ Other -- Number of living units; Number of bedrooms ??� Character of soil to a depth of 3 feet: SEPTIC TANK Water table depth r� v ❑ Type/Mfg Capacity No. Compartments b PKG. TREATMENT PLT. ❑ Method of Disposal ru Distance to nearest: MWell Foundation Pr000rty.Line 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 Ll Distance to nearest: Well Foundation DISPOSAL PONDS ❑ Property Line 1 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 Diktrict. 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 applican st call for all required inspections. Complete drawing on reverse side. Signed XTitle: Ai Date: FOR DEPARTMENT USE ONLY Application Accepted by Date_�,LZ Ct_ S Area Pit or Grout Inspection by Date Final Inspection by } � Date f if Additional Comments: - ❑ Stk 466 6781 ❑ Lodi 369- 1 ❑ Manteca 823-71 ❑ 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 INFO /l CAS�7H RECEIVED BY DATE �P.�ErR]MI7'%NyO.