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APPLICATION FOR PERMIT S)M JOAQUIN LOCAL HEALTH DISTRICL✓ 1601 E. HAZELTON 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 Josqui Coun Ordinance No.549 for fewage or No. 1862 for wall/pump and the Rules and Regulations of the San Joaquin Local Health District. ]? 9� _ �J1/},(f�j�J�./r�v�-J�j1/C-T Job Address y'�/�,J / r �"�'�� "'� ""-"' �"' � r City Lot Size�f� PM Owner's*Name /��/' Address Phone ZIL / Contractor's Name License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ e 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 ❑ TracyType of Casing Specifications C Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout C Irrigation ---Approx. Depth ❑ Egatem Surface Seal Installed by Repair Work Done C Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') V Depth Filler Material (Below 50') 'YPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence Commercial Other Number of living units: _ Number of rooms Character of soil to a depth of 3 feet: f Water table depth Ai'N Capacity SEPTIC TANK ❑ Type/Mfg No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal \� Distance to nearest: Well Foundation Property Line BEACHING LINE No. & Length of lines - Total length/sae =ILTER BED ❑ Distance to nearest: Well /60 t Foundation-4Z Property Line SEEPAGE PITS Depth Size 7 g h}t+mber �r. SUMPS ❑ Distance to nearest: Well 1W r Foundation �U 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 Lop) Health District. �-� shall not Home owner or licensed agents signature cartifies the following: '"I certify that in the performanca of the work for which this permit is issued. I employ any person in such manner as to become subject to workman s compensation laws of California."Contractor's hiring or sub-ccimnicting 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 Calif The applies ust call for require spectiorq• Comdata drawing on reverse s�ifde-.f' /'' 0 l 0Q Q d+�r-e�� Data:Sign Title:---o FOR DEPARTMENT USE ONLY Appliption Accepted by c] - - L AreaD - Pt or Grout Inspection Date Final Inspection —Daro s�& 4;-,r /al '� � A&VS Additional Comments: //� J S OF 4 / ❑ Stk 466-6181 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 nt - FEE AMOUNT DUE AMCVNT REMITTED CK H RECEIVED Sy DATE T77-'T NO. INFO Z� EHr124 IREV. 10/a31 EM tom