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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 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. ' G Job Address C" Lot Sae PM Owner's NameAddress - Phone Contractor /`e7 1 `er7p� Address �'�d'D, �' 'P' ST�icense Ne'�_a Phone TYPE OF WELL/PUMP: NEW WELL ❑ f WELL REPLACEMENT ❑ DESTRUCTION ❑ . PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ O7HER ❑ DISTANCE TO NEAREST: SEPTIC TANK 'SEWER LINES DISPOSAL FCD. - PROP. LINE,. FO AGRICULTURE WELL OTHER WELL ±° PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBL "CONSTRUCTIONSPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca pia. xcavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy /Type of Casing t_ Specifications Depth-of Grout Seal El Public Ll Other ❑ Delta � Type Of Grout�r Irrigation ---Approx.;Depth 'b Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump +-- H.P. i State Work Done Well Destruction ❑ Well Diameter °' Searing Material (top-5(Y)"l T Depth, Filler Material(Below 50') o; TYPE OF SEPTIC WORK: NEW INSTALLATION ❑/ REPAIR/AD DITIONV 1.DESTRUCTION ❑ (No septic system permitted if-public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial _ Other Number of Irving units:! Number of bedrooms Character of soil to.8 depth of 3 feet: ater table depth SEPTIC TANK J ❑ Type/Mfg / Capacity No. Compartments i PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line "1' LEACHING LINE No=& Length of lines 9y/r f Total length/sae FILTER'BED L-1 /•Distance{to nearest: Well_ Foundation Property Line �r SEEPAGE PITS El Depth t Size__— I Number r SUMPS - �f ❑ pistanceFto nearest: Wel( � 1 Foundation, � _ _ Property Line f DISPOSAL PONDS. ❑ t r ✓ Y-✓/ 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 J 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 shag not employ any person in such ma r as to become subject to workrna&s'cormpersatlon laws of California."Contractc4hiring or sub-contracting signature ! certifies the following:"I c hat 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 c f uired mplata drawing on reverse side. Signed Trtle: Date: FOR DEPARTMENT USE ONLY Applicatiori Accepted 6y Date OG Area Pit or Grout Inspection by l Date Final Inspection by 2s Date. [difionat Comments: Stk 466-6781 ❑ Lodi 369-3621 C Manteca 823-7104 ❑ Tracy"> 5 11 Applicant- Return all copies to:Envirorimentaf Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 96201 FEE NFO AMOUNT DUE• AMOUNT REMITTED CASH CK 9 RECEIVED BY DATE PERMIT'NO. A - Eli 13.24IREV.1/55) EH 1428