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�-► APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 A PERMIT EXPIRES 1YEAR 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 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. '�j� /_ _ / Job Address d / &XO // o��/ �/ City Lot Size 70 An. PM Owner's Name e I�NrL�1L� Address LT Phone Contractor ,Z Address License No. Phone 45 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O 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 ❑ Tracy ' Type of Casing Specifications FI Public n Other F1 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_ 4 Well Destruction ❑ Well Diameter Sealing Material (top 501 `v Depth Filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION 1 1 DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) ( (�, Installation will serve: Residence v Comrhercial Other C Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Qr-, Water table depth SEPTIC TANK Type/Mfg 66yLL _ 6� Capacity a/- '�- No. Compartments Z PKG. TREATMENT PLT. ❑ I Method of Disposal \ Distance to nearest: Well O0 Foundation Property Line 's LEACHING LINE Lx No. & Length of lines Total length/size l�© FILTER BED ❑ Distance to nearest: Well Ind l Foundations Property Line 3� a SEEPAGE PITS IU,"Depth Size Number SUMPS Ll Distance to nearest: Well , foundation © � Property Line � f 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 Di§trict. 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-_1�11 tion laws of California." The applicantmust call for all required spe tions. Complete drawing on reverse side. � / q Signed X Jc�/G Title: Clf-e4o4yenq Date: FOR DEPARTMENT USE ONLY 1 Application Accepted by z' // /�C Date 1' — F Area it or Grout Inspection by C Date�y Final Inspection by Date Additional Comments: ❑ Stk 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 FEE INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMI 'N0. L "� c7 f x .� EEH 13-24 H 11-2BfREV.t;xs1� ,: .. '. ;� '":-��-, �,!- -.�