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APPLICATION FOR PERMIT SAN JOAQUIIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District fora 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. Job Address ® t City Lot Size PM Owner's Name 9Ao• Address � � 4Wt 16;%0OW4 phone ZZ Contractor Address License No. Phone —T_Y,PE_OF WELL/P_UMP_;—..—,_.,,,,,,,,"-NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES DISPOSAL FLD. PROP. LINE, ` } FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS F INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing i ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications L7 Public ❑ Other Ci Delta f Dept 3 of Grout Seal Type of Grout 1 I I Irrigation --Approxi Depth I i Eastern ^ Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done - k Well Destruction ❑ Well Diameter Sealing Material (top50 1' 1 Depth Filler Material (Below 50') a . TYPE OF SEPTIC WORK:'-NEW INSTALLATION l 1 REPAIR/ADDITION I DESTRUCTION I I (No septic system permitted if public sewer is i' available within 200 feet.) Installation.will serve: Residence_. Com ercial_ Other y Number of,living units: Number of bedrooms ,i C1iaracter of-soil to a depth of 3 feet: _ ' Water table depth SEPTIGTANK r) ❑ T el Mf I r� r Type/Mfg 9 _Capacity No. Compartments i PKG. TREATMENT PLT. ❑ - T Method of Disposal ` r? Distance to nearest: Well FoundationProperty.Line '.� LEACHING LINE ❑ No. & Length of lines.,) � Tgta! length/size FINER BED [ Distance to.nearest: ;Wiell Foundation /.�-.-- Property Line ..._.,Z, _ SEEPAGE PITS I ) Depth I.Size r Number + ilk Sul MPS L-] Distance to nearestW : ell Foundation Property Line APOSAL PONDS ❑ f 1 `r� � I hereby certify that 1 have preparesfrthisa-pplication`and that the work will be done in accordance with San Joaquin county ordinances, state lams; and rules and regulations of the San Joaquin local Health,Diltrict- w w -_ . Y '� --.- _ ,__ f Home owner or licensed agent's signature certifies tl a following: "I certify 5 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 subikho workman's c'omperisation laws of California:" Contractor's hiring or sub-contracting signature pl certifies the following:."I certify that in the performance of the-work for which this permit is issued, I shall emoy persons subject to workman's compensa- tion laws of California." '^ x^ -The applicant must call for I r uir mspect' s:'Co" . late.drawing on reverse side. Signed X Title: Date: FO,0,116EPARTIMENT USE ONLY Application Accepted by Date V f Area r 1 y� Pit or Grout inspection byDate Final Inspection by Date Additional Comments: t ❑ Stk 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 2009, Stk:, CA 95201 t "FEE`S—AMOUNT DEUAMOUNTRMTEbC ECEIVEbBY GATE ?ERVI7NK INFO 0 . +.EH13-241REy.rin5) 0, '7 S ) 3 �V &k;3EH 14-28