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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 xw,. 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 i { Local Health District. 4 I Job Address yy C,a 7r City i r"Y'404V Lot Size GA PM Owner's Name Address l+yy C-51YYb4 0 { M Phone !!! Contractor Address GOO.t `QL✓t'` �, /'p "a License No. phone TYPE OF WELLlPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCT10N ❑ ' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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 ❑ hdusirial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ❑ Domestic/Private ❑ Gr"el Pack Dia. of Well Casing i I ❑ Tracy Type of Casing S ecifications M Piubtic 11 Other Cl Delta p Depth of Grout Seal Type of Grout _ I I Ishrigation ,__Approx, Depth I I Eastern' Surface Seal Installed by .i a Repair Work Done U Type of Pump H.p State Work Done _ well Destruction ❑ Well Diameter Sealing Material (top 50') } Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is h S Installation will serve: Residence-L— Commercial_ Other available within 200 feet,► ' Number of living units: --L— Number of bedrooms X Character of soil to a depth of 3 feet: A Water table depth SEPTIC TANK Type/Mfg &e C NoCompartments o 2a'a . pments .x �� PKG� TREATMENT PLT. I-] Capacity / . t Y Method of Disposal Distance to nearest: Well D ' Foundation zS Property Line 5" F i LEACHING LINE PI No. & Length of lines / V0 i Total length/size �G Y' FILTER BED ❑ Distance to nearest: Well Foundation Property Line � 4 }SEEPAGE PITS 11 Depth Size le _ Number r SUMPS V Distance to nearest: Well o?0. _ Foundation -2-f" Property Line -r- 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 rulesiand 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 FFF employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws of California." The-iipplicant mus call for all required inspections. Complete drawing on reverse side. Signed Title; Data; g t OR DEPARTMENT USE ONLY f Application Accepted by Date 1 Area Pit or;Grbut Inspection by Date Final Inspection by Date�_ . 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 4 F FEE AMOUNT DUE AMOUNT REMITTED INFO CASH RECEIVED BY PATE PERMIT ND. i E t3-241AEY.1/x51 I14-Ze