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APPLICATION FOR PERMIT SAN JOACIUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA s Telephone (209) 466-6781 ' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED F (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. f th application is made in compliance with,San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/p'ump and the Rules and Regulations of the San Joaquin k Local Health District. apiycc 7 Lot Size r PM t Job Addres$� TM City �y Phone Owner's Name �' Address .A�'` F �7J2� Phone .�67S Contractor l. Q x'` h Address icense No. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ f F PL)MP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 11 i pISTANCETO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �C) ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑':Tracy Type of Casing Specifications T — I�l Public ❑ Other 171 Delta �• _Depth of Grout Seal Type of Grout 1 Irrigation ..Approx.-Depth I Eastern Surface Seal Installed_ by - i Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 t Filler Material (Below 50') _Depth. - TYPE OF SEPTIC WORK: NEW INST LATION REPAIKIADDITION i I DESTRUCTION (J,(No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence 7 Commercial— O ther Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg Capacity—4-WO—07-j- No, Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well tC0 Foundation + &C>_' Property Line LEACHING LINE No. & Length of lines R J Tota,length/size FILTER BED ❑ Distance to nearest: Well Faundation 4�ol- Property Line I SEEPAGE/PITS ( I' 'Depth ,- Size Number �Z^f SUMPS•- .�Q' Distancee fo nearest: Well F6undafiori Property Line ..,. r DISPOSAL PONDS I ❑ �"�-�.� -.�', # 'k I hereby certify that I ha--ve,prepated this application end 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-strict. Homeowner 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 F certifies the following:"I certify that in the.performance of the work for which this permit is issued,l shall employ persons subject to workman's compensa- tion laws of California." The applicant`must call for all require inspections. Complete drawing on reverse side. SignedW "�'r C� !Ol"Y�i Title: _iso ata: X11^ Sao s FOR DEPARTMENT USE ONLY '2 Area Application Accepted by - �X 4 Date 13,�y Pit or Grout Inspection by Date Final Inspection by `�� Dat./ 74 + Additional Comments: - ❑ Stk 466-6781' C7 Lodi 369-3621 ❑ Manteca '823-7104 0.Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. azelton Ave., P.O. Box 2009, Stk., CA 95201 AMOUNT DUE' AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. +` FEE CASH ' )NFO /�Vl _ r.EH 13-24(REV.1/n5) 170 �� EH 14-2e