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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone !2091 466-6781 COPY 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. '1 Job Address .r1 r �� r' �-�� Book 1lDl Lot Size d -`� PM City ;I M Owner's NameZ1, Address f73i c�t1 t� �C Phoneme n Contractor' ~ ! Address f"?/_�, G 4� �.C� j1 License No Phone '�7 F ' TYPE OF WELL/PUMP: NEW WELLA WELL REPLACEMENT 77, DESTRUCTION ❑ PUMP INSTALLATION ' SYSTEM REPAIR ❑ OTHER 0 _ f DISTANCE 70 NEAREST' SEPTIC TANK 'SEWER LINES DISPOSAL FLD./— r, PROP, LINE �-a_ � 0 FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS �?O -INTENDED USE + TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 'Open Bottom C1 Manteca Dia. of Well Excavation " Dia. of Well Casing 5 ` XDornestic/Private °N © Gravel Pack W ❑ Tracy Type of Casing -3�r�� Specifications Fl,Public ,� Cl Other n Delta Depth of Grout Seal Typg 9f/Grout 'r7��WIT IF 1 1 Irrigation ! �` pprox. Depth I i Eastern ^urface Seal Installed by l ` [ n _ Repair Work Done ❑ Type of Pump +��' H.P. State Work Done -Well Destruction C Weil Diameter Sealing Material (top 501 i i Depth Filler Material (Below 501 TYPE OF SEPTIC WORK. NEW INSTALLATION I i 7rFAlF ADDITION ; 1. DESTRUCTION € 1.(No septic system permitted if public sewer is I. available within 200 feet.) 1 r lnstallatjon will serve Residence Commercial_ Other Q -Number of living units: Number of bedrooms .ry"i Character of soil to a depth of 3 feet: Water table depth s SEPTIC TANK 1!o ❑ Type/Mfg Capacity No. Compartments i!PKG" TREATMENT PLT. ❑ rt Method of Disposal ri ' 1 Distance to nearest: Well Foundation F Property Line ♦:li Yid : + ''LEACHING LINE D ..No. & Length of lines Total lengthlsize r FILTER BED ❑ Distance to nearest: Well Foundation Property Line - i SEEPAGE PITS .It J I ..Depth Size Number SUMPS + 0Distance to nearest: Wel! Foundation Property Line ; DISPOSAL PONDS 'i. ❑ i I hereby certify that I tave prepared this application and 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 District. 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.41 certify that 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.:— "The applicant m t call for all required inspections.;Complete drawing on reverse side. I i `Signed Title , 'K-7/ rr�_r� �- Date: r R DEPARTMENT USE ONLY Application Accepted by # Date �.`�L Area . Pit or Grout Inspection by rC%u �' � D.::, y Il -Final Inspection by Date 1 P4 ` ' Additional Comments::J, - +' + ❑ Stk 466-6781 ;i ❑ Lodi 369-3J01 ❑ Manteca 823-7104 ❑ Tracy 835-6385 y Applicant - Return allcopies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r iFEE I� AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. i FIP k-+;EH 1428-2+t(REV,1-5)Sl EH 14 ;l f 0`;,, v-0