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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT d 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1-YEAR FROM DATE IS {Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/o in tall the w;1d described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well d the Had of the San Joaquin Local Health District. QQ' Job Address �,t✓w / ]s'�� City-E/a�`.,,c-y.�r!`ot Size PM . . Owner's Name :59F / -IWAddress i J/}'+�le W a T Phone Contractor Ap.al- 420 Address 3 ^� ense No. 140 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Li ` 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 PROBLEMAREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f'1 Public ❑ Other f.1 Delta Depth of Grout Seal Type of Grout_ _ I Irrigation __.Approx. Depth I I Eastern Surfa eal Installed by Repair Work Done ❑ Type of Pump H.P., State Work Done_ Well Destruction ❑ Well Diameter Se I (top 50'I Depth -,;Fit rr• �+en I (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION fR DITION I DESTRUCTION I I (No septic system permitted if public sewer is prf Installation will serve: Rest enceavailable within 200.feet.) Commercial_ Other _ Number of living units: Number of bedroo s Character of soil to a depth of 3 feet: �/� Water table depth 14 SEPTIC TANK Type/Mfg 4WL 1 Capacity /" No. Compartments PKG. TREATMENT PLT.❑ Methodof Disp�sal Lf ¢ 11 Distance to nearest: Well J�12 _ Foundation Propeny,Line zfB f LEACHING-LINE �]�/ No. & Length of lines Agal Total length/size 04 FILTER BED . Ll Distance to nearest: Well 411`e Foundation 020+- .. Property Line ZOO - SEEPAGE PITS Depth - ,(Z _Size Number SUMPS ] Distance to nearest: Well Foundation Property Line �Q DISPOSAL PONDS ❑ L <�I I 1 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. Home owner or licensed agent's signature certifies the following: F[certify that in the performance of the work for which this permit is issued, I shall not employ any person in such rriarmer as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the followin ^'f 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 Califo The applican t allo I squire i dr'aTiw`ing an to rse side. Signed X Title: r Dia � gQ 1-- FOR DEPARTMENT USE ONLY / I Application Accepted by r Date �jJ Area_ Pit or Grout Inspection Date Final Inspection by l/h..lrll _ Date Additional Comments: ❑ Elk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823.7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 T/A113` L 1/I15�/G✓ate. FEE AMOUNT DUE AMOUNT REMITTED 'CASH ;RECEIVED BY DATE PERMIT'NO. INFO //