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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 'PERMIT EXPIRES TYEAR 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. 7 i � Job Address d City�.�- Lot Size PM Owner's Name JAddress 4 Lv F Phonei'[�� 0�/ �? 1 7 7 G _Phone - g Contractor FL C,-" '�s�—Address J�� License No. - TYPE OF WELL/PUMP! - NEW WELL _ TWELL REPLACEMENT❑ "" OESTRIJ'CT10N-� T _ + PUMP INSTALLATION ❑ SYSTEM REPAIR D OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL `� 4, dTHER-WELL • PITS/SUMPS INTENDED USE TYPE'OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONSi i LIIndustrial ❑ Open Bottom, © Manteca Dia. of Well Excavation Dia. of Well Casing Specifications EJ Domestic/Private ❑ Gravel Pack ' '� El Tracy f Type of Casing r'1 s Type of Grout - M Public ❑ Other /'. Delta` Depth of Grout Seal E1 1 I I Irrigation —.Approx. Depth l I Eastern� Surface Seal Installed by �_� � - r ((( Repairmark Done ❑ Type of Pump r H.P. �_ _ State Work Doney�J� Well Destruction [-1WellDiameter �Sealing:Material Atop 50')�-" — € Depthr Filler ial IBelow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I ! DESTRUCTION I } {No septic system permitted if public sewer is yj available within 200 feet.) Installation will serve:—Resii9ence---Z Commercial— Other Number of living units: --I— Number of bedrooms . t j Character of soil to a deWater table depth �ptth�3 feet: CAA n s 1^ SEPTIC TANK I� Type/Mfg 0-9Z /� L ~Capacity /&dC2 No. Compartments Z Method of Disposal PKG. TREATMENT PLT. ❑ •''� � Distance t o+nearest: Well /649 Foundation. r Property Line&xg J + LEACHING LINE No. & Length of lines �� _ Total.length/size 4, f z�� FILTER BED ElDistance to nearest: Well Vag! _ Foundation tiD Property Line J� SEEPAGE PITS f It/ Depth '�r _Size _6 f� "Number 424. SUMPS `' f Cl Distance to nearest: Well Foundation �� "�Pfoperty Line DISPOSAL PONDS t -O ,E 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 District. 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 perfofmance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." l k The applicant must call for all required inspections. Complete drawing on reverse side. Signed ){ Title: Date: S 1 - - - i FOR DEPARTMENT USE ONLY Application Accepted by f� Date S Area 7Vt Pit or Grout 1lnspection by Date_ Final Inspection byy 'Date'J" ` Additional Comments: ❑ Silk 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 2019, Stk., CA 95201 CK F FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY �BJA/TE PERMIT NO. ♦.EH 13-24(REV,i i H 5) ter/ r EH 14-2a V�