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APPLICATION FOR PERMIT r 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) r 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. yn, 6. Job Address o y,n" 0 / �r City Lot Size PM Ownei s Name 04/ /z.�r Address '/� Phone / 7 �y9 Contractor �� Address / r License No.L200;1_Phone 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 _ l INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS tr�� ttt ❑ 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_. �. I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 ` Depth Filler Material (Below 501 ,r TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence`� Commercial_ Other / Number of living units: Number of bedrooms V `ms 3. Character of soil to a depth of 3 feet: qp ,�aarn Water table depth I zt SEPTIC TANK ❑ Type/Mfg /. Q pPG Capacity.-1� No. Compartments ` PKG. TREATMENT PLT. ❑ r / Method of Disposal %F` Distance to nearest: Welles Fouqdation� Property Line LEACHING LINE ❑ No. & Length of lines _ Total length/size �rr FILTER BED ElDistance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number .. SUMPS ❑ Distance to nearest: Well Foundation - Property Line 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. r 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." Contractors 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 work an's compensa- tion laws of California." V The applicant must call for allrequiredinspections. Complete drawing on rave a side. Signed X�: ALJ e kz� Title: Date: u �(1/FOF D ARTM NT U E ONLY , Application Accepted by /i P/e" Date `L / Area Pit or Grout Inspection by Date Final Inspection by Date-� L Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 LApplicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEINFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 8Y `\ DATE PERMIT'NO. L - EH 1}N TREY.r/x51 IYQ (Ta O EH 142E ♦ 1/