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APPLICATION FOR PERMIT SAN JOAQUIN,L'OCAL'1HEALTH DISTRICT M 1601 E. HAZELTON AVE., STOCKTON, CA Telephone {209)--466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Ni Qf 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 Regulationsofthe San Joaquin Local Health District. F- y ; Job Address I �/��.ii.V 47.' "`^ ±;rte Cij !~:R Cit„� ; +s- `"T Lot Size e2e '7P� PM l` Owner's Name � '� = Address Alei? Phone 1«�N � 1�d �Irs� �,X' Contractor >� a�t1E'[�" I_Address�l License No.`T6b rT Phone TYPEOF WELL/PUMP: NEW WELL 2S WELL REPLACEMENT ❑ DESTRUCTION ❑r SYSTEM REPAIR_ ❑ .. OTHER , PUMP INSTALLATION 13 . ❑ DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES Q4 DISPOSAL FLD. PROP. LINE FOUNDATION fD- AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �rr s ❑ Industrial `W Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing r 'Domestic/Private F1 Gravel Pack LJ Tracy Type of Casing S FE>' Specifications ! ❑ Public , ❑ Other ❑ Delta Depth of Grout Seal Type of Grouteaft,�� ❑ Irrigation �SVlapprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ • Well Diameter Sealing Material {top 501 s Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial• Other Number of living units: Number of bedroomsJ. Character of soil to a depth of 3 feet: Water`table depth l a SEPTIC TANK ❑ Type/Mfg r Capacity +R No. Compartm ents'� � + -�` ' Method of Disposal' PKG. TREATMENT PLT. El �f � ,�. Distance to nearest:;,, 'Well Foundation Property Line ! LEACHING LINE ❑ "No:& Length-of lines �^`'`� Total length/size { FILTER BED ❑ • Distance to nearest: Well s Foundation r Property.Line � # i SEEPAGE PITS ElDepth Size Number SUMPS ❑ „ Distance to n_earest: . Well Foundation Property Line t DISPOSAL PONDS ❑ ' f 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 performance of the work for which this permit is issued, l shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required in§pecti . Complete drawing on reverse side., Signed Title: Date: i FOR DEPARTMENT USE ONLY i Applic ion Accepted"by Date Z Area d Pit or ro�Tspectioh by Date� Final Inspection by f.Date A ditional Comments: Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 __ plicant=Retum all copies to: Environ menial Health Permit/Services 1601 E. Hazelton Av_e., P.O. Box 2009; Stk.,'CA 95201 Y l FEE INFO AMOUNT DUE AMOUNT REMITTED C RECEIVED BY. !DATE PERMlT NO. + Eti 1 10 }24(REV.1/e 5) �Q, OC? ` • EK 1426 k