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APPLICATION FOR PERMIT �SN JOAQUIN LOCAL HEALTH DISTRICT tiiiE. HAZEL T ON'AVE., STOCKTON, CA -`°TeleP hone (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. JAddress `w[)F/J � City V f��U Lot Size PM ob f -" — i �nWIC-SICIA') Tr3N Phona D Owner's Name WA Address "a f- Contractor �`_ Address _ License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL-REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE t I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS y INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION-SPECIFICATIONS I ❑ Industrial ❑ Open Bottom ElManteca -.Dib'. of Well Excavation Dia. of Well Casing ❑ Domestic7Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public ❑ Other ❑ Delta 'Depth of Grout Seal Type of Grout I I Irrigation __Apprcx. Depth I 1 Eastern (Surface Seal Installed by Repair Work Done ❑ Type of Punp H.P. State Work Done , .Well Destruction ,❑ Well Diameter Sealing Material (top 50') i I Depth Filler Material (Below 501 j TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION f 1 Wo septic system permitted if public sewer is available within 200 feet.) I Installation.E will serve: Residence X Commercial Other d Number of living units: A— Number of bedrooms .41 Character of soil to a depth of 3 feet: �t�h�' -- Water table depth �4M1 ` SEPTIC TANK ❑ Type/Mfg Capacity No. CampBrtments PKG. TREATMENT PLT. ❑ - I Method of Dispo a Distance to nearest: Well Foundation .. Property Line LEACHING-LINE -.No: & Length-of lines - 1 ^ LWb - Total length/size ), i FILTER BED ❑ Distance to nearest: Wellf¢��Foundation-W" Property Line IJ, SEEPAGE PITS I I Depth I Size Number w` l SUMPS ❑ Distance to nearest: Well Foundation Property Line 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 Di§trict. 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, l 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 t6 workman's compensa- tion laws of California." -' The applicant must call for all required inspections. Complete drawing on reverse side. A d LJ A) .ER _ Date: y Signed X Title: I , FOR DEPARTMENT Ugli ONLY Application Accepted by Cit Date Area Pit or Grout Inspection by .Date Final Inspection by Da Additional Comments "L Stk 466-6781 -LJ Lodi 369-3621_ ' El Manteca 823-7104 ❑ Tracy 935-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE I AMOUNT DUES-',~'AMOUNT REMITTED C K RECEIVED BY DATE PERMITNO. ti INFO 1 � a,EH 13-24IREV.1/951 �t 1 � s9d_ 6 � - EH 14-26 dT