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IL APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. 1 Job Address/ City Lot Size 10 Q'�~ PM Owner's Name a^`Address `s Phone J f /^ p i Contractor's Name License No. 6 rf Phone to I' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT I DESTRUCTION ❑ PUMP INSTALLATION,❑ SYSTEM REPAIR `7 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE r TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS G Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation pia. of Well Casing C Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout •---'""O Irrigation pprox. Depth C 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 Filler Material (Below 501 1 TYPE OF SEPTIC WORK: NEW INSTALLA�TION &;—REPAIR/ADDITION.—DESTRUCTION Q-tNo septic system permitted If public sewer is rn � +yJSirM1 available within 200 feet.) Installation will serve: R nce— Commercial_ Other k3 Number of living units: Number of drooms /L 1� Character of salt to a depth of 3 feet: Water table depth SEPTIC TANK/ Lt—Type/.Mfg Capacity No. Compartments PKG. TREATM9NT PLT. 7 ' i - .. Method of Dis osal yy ��''''�� `� 1��1p _J - , Distance to nearest: Well J�.v Foundation 0 Property Line I' �+ LEACHING LINE, L5' No. & Length of line Qr - Total length/size FILTER BED Er—lDistance to nearest: Well I 1 ! Foundation 1 , _ Property Line SEEPAGE PITS Depth �1 ~Size "� N mhe fit- SUMPS 'I SUMPS to nearest: Well ��,,�, Foundation 8 t Property Lrne DISPOSAL PONDS i_] r a 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 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."Contractors hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." f The app)Icant m t ca rat) spections. Complete drawing on reverse aide. y � /U Signed Y � Title: 66", Date: .-Y v • OR DEPARTMENT USE ONLY Applicatron Accepted by Date �/ 4�._,� Area 5,p/ p Pit Grout Inspection by Date �_�S Final Inspection by Date s Additional Comments: ❑ S& 466-6781 ❑ Lodi 36.9-3621 ❑ Manteca 823-7104 : .❑-Tracy 835-631 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMI7'NO. .E 13-24 TREY.10l83) L, EHN 1426 A `l