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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 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 is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welllpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address, J � '/v, G �� ' City' Lot Size PM t° � /4� , i.�� [�1? . . ,9W Q� lG� Owner's Name f✓ Address �_ Phone Contract 6r%✓" �, i•C -? Address��, ��07 '�� License No.3297 ZG' Phone_?(S- SUS TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS © Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1-1 Public Cl Other F Delta Depth of Grout Seal Type of Grout I 1 Irrigation Approx. Depth '("I-Eastern J Surface Seal Installed by..-...- Repair y -Repair Work Done ❑ Type of Pump H,P. State Work Done-- Well Destruction ❑ Well Diameter SealinMaterial (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION LI DESTRUCTION I I (No septic system permitted if public sewer is 4available withiri.200 feet.) ( f Installation will serve: R deuce_ Commercial_ Other Number of living units: Number o b droo`ms Character of soil to a depth of 3 feet: L Water table depth Ro+ SEPTIC TANK .` Type/Mfg Te`i l.� iL.i:t-L.( " Capacity 01:.t2.o- No. Compartrnent� I PKG. TREATMENT PLT. ❑ 4°• a '�,` h .` Method of Disposal , Distance tq'ne`arest:' Well Qti oundation Q Property Line LEACHING LINE No. & Length of lines oC`�� t-� . �.�i. f{a 1-L.-'Totat length/size 0 X2 �" Q X� ..�. FILTER BED ❑ Distance to nearest: Well A� Foundation ti•C E Property Line----715' SEEPAGE PITS `q Depth 5 Size *�)�'' y f Number SUMPS Ll ' Distance to nearest: Well J& `4 -Four'idation� '� y 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 i rules and regulations of the San Joaquin Local Health DiMrict. 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." 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,-1 shalE employ persons subject to workman's compensa- tion laws of California." The applica must calor a required inspections. Complete drawing on reverse side. Signed Title: �. _ Date: FOR DEPARTMENT USE ONLYU cy PP p y �« � \ Date O ��/d Application Accepted b Area or Grout Inspection by Date SC�d Final Inspection by �� Dat (/ f Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i FE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. +.EH1324(REV.1/N 51 EH 1428 Wavle Qr�Z