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4-?J n APPLICATION FOR PERMIT n SAN JOAQUIN LOCAL HEALTH DISTRICT SCANNED 1601 E. HAZE T ON AVE., STOCKTON, CA Telephohe (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 of No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address O� • City Lot Size _ � �'PM Owner's Name u P% Address �'+ Jrn Phone Contractor �Address License No. Phone 8 A TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ DISTANCE TO 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 ❑ Industrial © Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications r"1 Public f-1 Other Ci Delta Depth of Grout Seal Type of Grout . I I Irrigation --Approx. Depth t I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 3 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.3 REPAIR/ADDITIO DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet-) Installation will serve: Residence Gommerciai— Other I Number of fiving units: J— Number IldrooT S. Character of soil to a depth of 3 feet: -3A A)Z" LAAWater table depth SEPTIC TANK Bj Type/Mfg _4?_b_ V L ' Capacity �d No. Compartments PKG. TREATMENT PLT. ❑ / Method of Disposal l� Distance to nearest: Well T Foundation erf 5 Property Line LEACHING LINE llYNo. & Length of lines dd Ttal length/size FILTER BED ❑ Distance to nearest: Well Foundation • Property Line a L7 66, SEEPAGE PITS 1 1 D pth 1+0 Size W Number SUMPS Distance to nearest: Wall Foundation Property Line _ i DISPOSAL PONDS ❑ - I hereby certify that I have prepared this application an&-thaf rhe work will be done in accordance with San Joaquin county ordinances, state laws, an rules and regulations,of the San Joaquin Local Health Diltrirt. Home owner or fii;oppGd agents signature certifies the follovr�ng: "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'tI6 -become subject to workman's compensation laws'of.California."Contractors hiring or sub-contracting signature certifies the following: 1'csrtify tha£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." l The applicants must call for a required inspections. Complete.drawing on reverse side. Signed X title: Yw • Date: IFv�- FOP.,DEPARTMENT USE-ONLY.. Ajlicati 'Accepted by ��cf` Date f Area limit or `f Inspe Ion by l Date % inat Inspection byou rouDateL! � 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, Sik., CA 95.201 FEE AMOUNT DUE AMOUNT REMITTED CA H RECEIVED BY DATE PERMIT`NO. 5 �7 j ..EH 13-24{REV.t/A 5) INFO J 1 �^•--i 7 � 1✓�. TA) !c . 8 EH 14-2t! 1 !! I