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! APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL 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 well/pump and the Rules and Regulations of the San Joaquin Local'Health District. Q '� , /1 �� j Job Address 171 F +✓ IV17o /1 City ��j� Lot Size '�`'�,7� PM Owners NameAddress �� ;r� Phonek) Contractor z-� �y�-, Address . ./j _L License No. �,� Phone11 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FED. PROP. LINE FOUNDATION AGRICULTURE WELL _ OTHER WELL PITS/SUMPS I' INTENDED USE. TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing I ❑ Domestic/Private ❑ Gravel Pack CI Tracy Type of Casing SpecificationsJi F1 Public I Other Cl Delta Depth of Grout Seal Type of Grout € I Irrigation Approx. Depth l I Eastern Surface Seal Installed by _ Repair'Work Done ❑ Type of Pump H.P. State Work Done `! Well Destruction ' ❑ Well Diameter _ _ Seafing Material atop 50'l _ Depth Filler Material (Below ) ,{ TYPE;OF SEPTIC WORK: NEW INSTALLATION Rt-PAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet) Installation will serve: Residence r' Commercial—_ Other avr 'v Number of living units, Number offs-bedrooms___ Gharacter of soil to a depot of 3 feet: Q_ ff /fit Water table depth 1O \ SEPTIC TANK ids Type/Mfg • -- 3 Capacity__ "l ��J No. Compartments PKG. TREATMENT PLT. ❑ LL Method of Disposal ` Distance to nearest:. Well —J U Foundation �� i Property Line LEACHING LINE ❑ No. & Length of lines `r` ::r�%� Total length/sizeLeC/�efix- �� FILTER BED ❑ stance to nearest: Well ! `Fou dation / DiT� Property Lino 1\ SEEPAGE PITS 1-4'—Depth Size_._. ro ! )Number SUMPS I_l Distance to nearest Well �� r foundation N /o Property.Line '2 (;t (} t.�.t �r 4 i DISPOSAL PONDS C7 i hereby certify that I have prepared this application and"that the work will be one in accordance with San Joaquin icodhty ordinances, state laws; and rules and regulations of the San Joaquin Local Health District. Home iowner or licensed agent's signature certifies the following: "I certify thkin-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 person eat to-wor man's;compensa I tion,laws of California." Thee,applicant must callor II required inspections. Complete drawing on reverse side. C10A)= Signed X ETitle: Date: 'f FOR DEPARTMENT USE ONLY i Application Accepted by, f Date Area Pi r Grout Inspection by /l �,�� _�_ P Date Final Inspection by Additional Comments: Comments: ❑ Sik 466-6781 - ❑ Lodi 369-3621 ❑ Manteca 8;23-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/S,ervices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT OUE AMOUNT REMITTED CASH RECEIVED eY DATE PERMIT"NO. +.EH 1124(REV.r i H 5) EH t4-28PEE]