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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED IComplete 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 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. ? J� Job Address City 04 ' Lot Size ` PM or R 'Owner's Name ddress 'v hone /S f Contractor Address `� License No. Phone .. '7TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR LI OTHER ❑ C .40DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE `v\r ' :' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS © Industrial �❑,Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing f I © Domestic/Private t•❑ Gr,0�1 Pack ❑;Tracy Type of Casing Specifications .y p Public ; ❑ Iyer ❑ I eE .-Depth of Grout Seal Type of Grout ❑ Irrigation r- �p�prox. Depth ❑;FAkerY,n `>` S tlf ce Seal Installed by Repair Work Done !O Type�of,Pu__mP State Work Done # � Well Destruction ❑ Well Diameter. ' "z.-Seafing-M t4ia11`{top 501 Depth Filler Mate ial(Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION-[] REPAIR/ADDI ION, DESTRUCTION ❑ Mo septic system permitted if public sewer is available wit in 200feet.) i, Installation will serve: ;R'esidence— Commercial—I&—Other Number of living unit Number of drop J z �_ Character of soil to a depth aY3,feet: Water table depth SEPTIC TANK ` ❑ Type('Mfg l Capacity No. Compartments PKG. TREATMENT PLT. Els Method of Disposal..` Distance o nearest: Wet11 Foundation Property Line c �" LEACHING LINE ❑ No. & Length-,f�ines � Total length/size - FILTER BED �/ ❑ Distance to nearest: 1 Ielll Foundation Property Line ' y i SEEPAGE PITS �' �pth Size /P- SEEPAGE / Number ' SUMPS ❑rDistance to nearest: Well �� Foundation s Props y Line. +� .DISPOSAL PONDS ,� I I hereby certify that 1 have prepared_this application and that the work will.be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations Iof the San Joaquin Local Health District. � Home owner or licensed agent'ssigna re certifies the following: '9 cert AW)t in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subjecuto�workman�s j?mpensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "1 certify#hat-imthe performance%f the work f4 ich'this permit is issued, I shall employ persons subject to workman's compensa tion laws of California." The appli nt call for squire i 'ctions. Complete drawing n reverse side. � Signed Yr � _ Date: cr.a FOR DEPARTMENT USE ONLY Application Accepted by Date Arta Pit or Grout Inspection by Date j Final Inspection by Date�2 1 Qfj Additional Comments: X ❑ Stk 466-6781 ❑ Lodi 369=3621 ❑ Manteca 823-7104 ❑ Tracy835-6385Applicant- Return all copies to: Erivirolhmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 IFEE NFO AMOUNT DUE F AMOUNT REMITTED CASH RECEIVED BY LL DATE PERMIT NO. + C>C, EH 13.24 iREV.i/ 5Y F, EH 14-29 5