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3, APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 1711 „ 1A Fm Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described X 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. Job Address eW City T Lot Size PM Owner's Nam Address aZ4L Phone pb, mr 7 b 2 Z(-Ph 6 - to Contract Address License No. one 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 _ 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 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by p Repair Work Done El Type of Pump H.P. State Work Done j!' Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 ,J TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 270 feet.) Installation will serve: Residence_ Commercial_ Other 7 Number of living units: __/__ Number of b,I ooms / Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg _ . /�{r & Capacity._Z21M No. Compartments PKG. TREATMENT PLT. ❑ .cn r Method of Dis, I Distance to nearest: Well—bT-� Foundation_�� Property Line _ LEACHING LINE �No. & Length of lines _40Total length/size FILTER BED ❑ Distance to nearest: Well !0 r Foundation /d o, Property Line SEEPAGE PITS Depth Size 2 Number SUMPS Cl Distance to nearest: Well Foundation C Property Lim 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 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: "I 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 mus all for all r 'red spections. Complete drawing on reverse side. Signed CJ Title: Vr Date 6 FOR DEPARTMENT USE ONLY n� Application Accepted by G� n u Date -30 Area Pit or Grout Inspection by Date` � V Final Inspection by Date Additional Comments: ❑ Silk 466-6781 ❑ Lodi 368-3621 ❑ Manteca 823-7104 ❑ Tracy 835.6385 Applicant- Return all copies to: Environmental Health Penni[/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I EEE AMOUNT DUE AMOUNT REMITTED CCK a RECEIVED BY DATE PERMIT'NO.PERMITNO. ♦ EH 1428(REV,nasi / p t16