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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1 ( 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209)466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Uh y (Complete in Triplicate) , Application is hereby made to the San Joaquin Local Health District for a permit to construct end/o,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.. _City Lot Size PM r� Job Address - Owner's Name II "v`'L r Add ss t• Phone ,I Contractor's Name -- icens6No• Phoria 4 TYPE OF WELL/PUMP NEW WELL ❑ /',' WELL REPLACEMENT"EJ DESTRUCTION n PUMP'INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS C'ti INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑-Open-Bottom----G-Manteca-----Dia,-of Well-E.'cavalion - - - —.Dia.-of-Well-Casing--------- Daestic(Private 1, ❑Gravel Pack ❑Tracy Type of Casing___._— Specifications r ❑Public -11 `v!C7 Other ❑Delta Depth of Grout Seat __ Type of Grout 11 ❑Irrigation vl /---Approx.Depth Eastern Surface Seat Installed by CA Repair Work Done'%0,!.Type of Pump H.P._ __-State Work Done -r Well Destruct ❑ Well Diameter Sealing Material(top 50'! I f �. 'Depth Filler Material(Below 501 ' TYPE OF SEPTIC WORK: tNEW'LNSTALLATION❑ REPAIR/ADDITION❑ DESTRUCTION❑ 1No septic sVatem permitted if public sewer is_ ` r �� available within 200 feet.) Yr ~ Insaat taign wiill serve: Res rice _.�ComrnEicial Other Number of living units: Icl Nufnber of bedrooms Water table depth Character of soil to'a depth of 3•f`eet:SEPTIC TANK' Ty1p�e/Mfg ___ -_�- Capacity No.Compartments !" `. _ \ PKG.TREATMENT PLT.❑ Method of Disposal `moi Distance to nearest: Well___ __ Foundation Property Line -- 1 y''` 1 Total len h/size LEACHING--L-INE CJ No.`6 Length of lines a—__ gt 1 S FILTER BED, ❑ Distance to nearest: Well _.._ —. Foundation_.____.=Property Line 'r1 1 \ i----t —4 SEEPAGE PITS \ ❑ Depth Size t�y3'� Number 1 SUMPS � ❑ Distance to nearest: Well Foundation Property Line r ^� DISPOSAL PONDS Il t1 T _ I hereby certify that t have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,state laws,end rules and regulations of the San Joaquin Local Health District. 1 Home owner or licensed agent's signature certifies the following:"I,cerdfy 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 bathe work for which this permit is issued,1 shall employ persons sub iect to workman's Compensa- tion laws of California.'; •t Thea plica for I r/Juir tions.Complete cawing on r rse side. Signed)� 6 CEJ Title: Date: t FOR DEPARTMENT USE ONLY Application Accepted by Date Area [[ Pit or Grout Inspection by Date 2 Final Inspection by Deter rtlonal Comments: L r I j -Ml tk 466-6781 ❑Lodi 369-3621 ❑Manteca 8Z3-7104 ❑ racy ! Applicant-Return all copies to:Environmental Health Pormit/Services 1601 E.Hazelton Ave.,P.O.Box 2009,Stlk.,CA 95201 CK ill FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE •PERMIYNO. INFO t t ♦EH 1324(REV.10/33) EH 147E o