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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL—ION AVE., STOCKTON, CA Telephone (209) 466-8781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 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. p is Job Address City Lot Size 1 PM Owner's Name �r Address L Phone Contractor's Name TYPE OF WELL/PUMP: License No,. NEW WELL ❑ WELL REPLgCEMENTw❑; Phone PUMP INSTALLATION"0 DESTRUCTION ❑ DISTANCE TO NEAREST: SEPTIC TANK SYSTEM REPAIR'p "`O7FfER'❑ SEWER LINES i FOUNDATION a—��t DISPOSAL FLD. PROP. LINE AGRICULTURE WELL ' INTENDED USETYPE OF WELL OTHER WELL PiTS/SUMPS ) PROBLEM AREA CONSTRUCTION SPECIFICATIONS F ❑ Industrial LJ Open Bottom ❑ Domestic/Private Manteca Dia. of We(I'Excavation' ❑ Gravel Pack ID Tracy T Dia. of Well sing � ❑ Publicm Type of Casing Specifications ❑ Other ❑ Delta Depth of Grout Seal"q"" ❑ irrigation "' �� " , Approx. Depth ❑ Eastern Surface Seal Installed by ' . : �-;Type of Repair Work Done ❑ Type of Pump , Well Destruction ❑ WeU Diameter H P State Work Dane * [ Seating Material (top 50'1 / _ 1 (_ . Depth` 1 Filler Material (Below 50') . . ; 0& 3 fes. TYPE OF SEPTIC WORK; NEW iiVSTALLATION � REPAIR/ADDITION ❑ DE57RUCTfON_ ❑ iNa septic system permitted if public sewer is `J Installation will serve: Reside- `� available within 200 feet.) Commercial Other_�� p E Number of living units:_ Number of bedrooms /[ f Character of soil to a depth, 3 feet: t'- j< F '!k tom{ SEPTIC TANK r a r .r e�"+ r' 1 Type/Mfg,_ ff Water table depth PKG. TREATMENT PLT. ❑ Capacity fix No. Compartments' *� .,_ Method of Dispose! C. Distance to nearest: Wel( C t - t .Fo�u�nda�tion � " ,' �ti i.•,. Property Line^ '' LEACHING LINE 4OW 7 i W r.._ _..- M �` No. & Length of Lines � �- �.� s ; FiLTER BED ' Total Length/size - ) �! �a ,I$ Distance to nearest: Well Foundation -- ;Property Line k SEEPAGE PITS ❑ Depth A Ar Size _ �: SUMPS El Distance to nearest Wel! Numher DISPOSAL PONDS ❑ V Foundation' Property Line .. [ `� prepared this ! 1 , hereby certify that 1 have s application Xand that the work will be done in'`aceordance with San Joaquin'county ordinances, state laws, and rules and regulations of the San 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 i 1 employ any parson 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 permit is issued, I shall not tion laws of California." p y persons subject to workman's compensa- tion applicant must call for al required inspections. Complete drawing on reverse side. _ 'Signed r �1, Title: g Date: FOR DEPARTMENT USE ONLY A li°Iti ccepted by S ¢- Date 14—2� l,G A.MM =M-ate inal Inspection by L Additional Comments: - Date-'(0�a�`-'�F I ❑ Stk 466-6781 ❑ Lodi 369 3621 Manteca 823-7104 Applicant- Return all copies to: Environmen ea h Permit/Services 1601 E.❑Hazelton Ave.,Tracy P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED INFO RECEIVED BY CASH DATE PERMIT`NO. -EH 13.24(REV.]01831 EH 7426 S, tl - Com- �lbl$f•'i t.��t a��r