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APPLICATION FOR PERMIT � SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i ON AVE., STOCKTON, CA FILE C 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 '" r1"e ;�T� is application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Reguiatio of trie$an'�aquin Local Health District. �04Job Address City Lot Size PM Mo41 r / Address Phone T Owner's Na a Contractor Address G f License No Phone �✓ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO.. PROP..LINE , FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I_ t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing D Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1`1 Public 1 n Other ❑ Delta Depth of Grout Seal Type of Grout- .-I I Irrigation ; Approx. Depth l 1 Eastern Surface Seal installed by a = Repair Work Done ❑ Type of Pump H"P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 r �, Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTAt;LA-tiO l REPAIMADDITIOM I I DESTRUCTION € I INo septic system permitted if public sewer is C, available within 200 feet.) Instailatio r�will serve: Residence_ tvommerCiar- lOthpr, Number of living units: Number_of be o t '+� Water table depth Character of soil to a depth of 3 feet: �; � SEPTIC TAf�qK �]/Type/Mfg C09)7— Capacity Zap __' No. Compartments o PKG. TREATMENT PLT. ❑ I I ` ` Method of Disposal, Distance to nearest: Well%300 Foundation �'`�I Property Line ;• LEACHING LINE C4/No. & Lengthl'"ne . 0� T tal 1lIngth/sizeIF _ FILTER BED ❑ Distance to nearest: Well Foundatioln G j Property Line S t SEEPAGE PITS I*--Depth 2 Size .. ¢..f um#ter ��n, SUMPS Cl Distance to nearest: Well Foundatidn d"LJ r. - Prdperty Line — DISPOSAL ION05 ❑ 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. " A; Home owner!or licensed agent's signature certifies the following: "I certify that in the performance of the worts for which this permit is issued, I,shall not employ any Gerson in such manner as to become subject to workman's compensation taws ofSalifo►hia."Contractor's hiring or sub-contracting signature i certifies the following: "i certify that in the performance of the work for which this permit is issu4d,, hall employ persons subject to workman's compensa- lion laws of lCalifornia." The applican must call for required inspections. Complete drawing on verse s€de. a Signed X _____ Title: G-� Date: I OF Vi _ FARJDEPARTMF-N.T-.USE-ONt Y:--------.--_-____.._--._.. I Application Accepted by - Dates Area Pit r Grout Inspection.by ' ate'e�,Final Inspection by Dat f25 M Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Per mit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA95201 x FEE AMOUNT DUE AMOUNT REMITTED I CK RECEIVED BY DATE PERMIT'NO. INFO CASH (q�r� f{CASH ♦ EH 13-24 IREV.rin b7 /}...a /7 EH 14-2a