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APPLICATION FOR PERMIT_ i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 s PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is he,eby 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. �-- Cit Lot Size <3 dZVL_PM Job Address � � Y t7 J o/ 1 { Phane Owner's Name v �Address Contractor "ddress /2 Ar / Y _ -_- License No l� Phone �~ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES :DISPOSAL FLD. j PROP. LINE 9 FOUNDATION AGRICULTURE WELL OTHER WELL k PITS/SUMPS 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS s ❑ Industrial © Open Bottom O Mattt6ca* Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy . —.Type.•of-Casing' ' Specifications I"1 Public ❑ Other ❑ Delta i ,Depth of Grout Seal ,Type of Grout ! I Irrigation —Approx. Depth i I Eastern--.,' Surface Seal'Installed by ; t _ V 1 Repair Work Done ED Type of Pump _ H.P. State Work Done_ 111 Well Destruction— ❑ Well Diameter `" Sealing Material )top 50') { t*r� "? Depth Filler Material (Below 50') 4 t TYPE OF SEPTIC-WORK: NEW INSTALL TION REPAIR/ADDITION l I DESTRUCTION I 1 INo septic system permitted if public sewer is �:: available within 200 feet.) Installation will serve: Residence Commercial l—I -Other € *',e t Numberof living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth - SEPTIC TANK ❑ Type/Mfg Capacity /�r�c2 No. Compartments,, PKG. TREATMENT PLT. ❑ r, "# ff-.., L Method of Disposgi Distance to nearest: Well fd,f) Foundation�y,�� Prgperty Line t y 4 � , LEACHING LINE ❑ No. & Length of lines 6 T tal length/size FILTER BED ❑' Distance to nearest: Well oundation Property Linea ` / 5 b SEEPAGE PITS CI DepthY : Size _ r Number, SUMPS `Ll Distance to neares Well .� Foundation' 2D ', Property Line ro 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 taws, and rules and regulations!of the San Joaquin Local Health District. r 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."Contractors 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." ,p The applican ust call for require irispections. Complete drawing on reverse side. 4 s t A i r Signed X Title: Date: $ ^ 0_ i r FPREE ONLY AP lcation Accepted by.. Date r ofArea .Pior Gout Inspection byDa et �� Final Inspection by 1, Date!Akj:,— Additional Comments: i ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 ► 1 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201FEE , t INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY ^DATE ^PERMIT'NO. is + EH 13-21IREV.iTw s: "�'�. _w'-V