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APPLICATION FOR PERMIT 71 SAN JOAQUIN LOCAL HEALTH DISTRJCT 1601 E. HAZEL T ON AVE., STOCKTON, CA ' Telephone (209) 466-6781 PERMIT EXPIRES 1-YEAR FROM DATE ISSUE O I (Complete in Triplicate) . ply 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. Job Address r? �' City G4-L� Lot Size PM O net's Name Address PhofPhonL � ,5 I Contractor Y�J Address License N TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ t PUMP.INSTALLATION p SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE l FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS w' 011ndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing � Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications f l Public 1-1 Other iD Delta Depth of Grout Seal ' Type of Grout — I I;Irrigation —_-Approx. De h i I Eastern Surface Seal Installed by Repair Work Done Ffi Type of Pump H.P. S• State Work pone W Well Destruction ❑ Well Diameter Sealing Material ftop.50.) ii , Depth Filler Material {Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIR/ADDITION l 1 DESTRUCTION I F {No septic system'permi[trid if public sewer is , available within 200 feet.) Installation will serve: Residence, Commercial Other Number of living units:. .i,Number of bedrooms Character of soil to a depth of 3 feet: SWater table depth EPTIC TANK ❑ Type/Mfg Capacity C14PKGNo.Compartments. TREATMENT PLT. ❑ > �pd,pf Disposal Distance to nearest: Well Foundation Propertykl""net_ LEACHING LINE ❑ -No..9 Length of lines Total length/prkb ; e FILTER BED ❑ Distance'to nearest: Well Foundation I5>1 € gyp�ert Line SEEPAGE PITS i I Depth Size Ie' _ L r SUMPS Ll Distance to nearest: Well Foundation Property Liner1N DISPOSAL PONDS. El ; I hereby certify that I have prepared this application and that the work will be done in accordance with San Joa tures and regulations of the San Joaquin Local Health District. quin county ordinances, state laws, and 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 st call for all required inspections. Complete'drraawing on reverse side. Signed X Date: (. f �� j r FOR DEPARTMENT USE ONLY Application Accepted by Date ea P �� Pit or Grout Inspection by Date Final Inspection by � _��-�c�.l'/' � �%`'�'�•; r Additional Comments: Q �1 fir' f ❑ Stk 466-6781 ❑ Lodi 369.3621 O Manteca 823-7104 ❑Tracy 835-6385 App4cant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE l CK f— INFO AMOONT,DUE AMOUNT REMITTED CASH RECEIVED 8Y DATE PERMIT NO, I-24(REV.r L7b - 26 i