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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA 'Telephone (209) 466-6781 1 PERMIT EXPIRES�1 YEAR 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.'r: Joh Address L E r F Cit" G�[ C. Lot I Size 24 J'. PM Cddress O Phone99 9–o CO2 Owner's Name Contractor&4 �Dl ress l /y n' License No.nS-z�IV}Phone �! i TYPE OF WELL/PUMP: NEW WELL L1WELL REPLACEMENT El DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 E.] Gravel Pack Ll Tracy Type of Casing Specifications F1 Public LlOther 1-1Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well diameter Sealing Material Itop 50') Depth I Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION e REPAIR/ADDITION ❑ iDESTRUCTION ❑ INo septic system permitted if public sewer is r available within 200 feet.) • � k' Installation will serve: Residence Commercial_ Other Number of living units Number of bedrooms Character of soil to a depth of 3 feet: Water table depth f a {� j SEPTIC TANK Cl Type/Mfg tf Capacity No. Compartments S PKG. TREATMENT PLT. ❑ Method of Disposal r E Distanc to_ nearest: Weld'S S Q Foundation' 1 6 Property Line c, LEACHING LINE ❑ No. & Length of lines Total length/size Z 1 FILTER BED C1Distance to nearest: Well CQD oundation Property Line_ ��— —��— ' 9 SEEPAGE PITS ❑ Depth t Size Number p ; SUMPS ❑ Distance to nearest:. '- ..Weil �Q Foundation Property Line L� ' DISPOSAL PONDS ❑ } I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and I 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,I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all re ired ' spections Complete drawing on reverse side. _ Signed Title: � Z-- Date: ( R DEP4VRT�fNENT USE ONLY Application Accepted by nA��:_�— Date_ n A Area Pit or Grout Inspection by' ate �-1�=g Final Inspection by n\h..`1�.. n, c.M,r� Date 91A 19–t Additional Comments: ❑ Stk 466-6781 El Lodi 369-3621 ❑ Manteca..823-7104 El Tracy 835 63$5 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.; CA 95201 + FEE AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATE PERM17'NO. f INFO . + EH 13-24[REV:t i n 5I 767 a EH 14-28 �d Gp VA .` .. ..