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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT d F 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 � PERMIT EXPIRES TYEAR FROM DATE ISSUED _ (Complete in Triplicate) Application is,hereby made to the San Joz.aquin Local Health District for a permit to construct and/or install the work herein described. This application is i made in compliance with San Joa4uin County Ordinance No.549 for sewage or No. 11362 for well/pump and the Rules and Regulations-of the San Joaquin Local Health District. 1 1 City d Lot Size PM t Job Address } r t , Phone Owner's Name e �.,.,.►--m- _-� -!� L Phone i License N 4 71 Z 1 Contractor Addie Y ' TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT 17DESTRUCTION El PUMP INSTALLATION Els :` + SYSTEM-REPAIR ❑ OTHER ❑ f i a DISTANCE TO NEAREST: SEPTIC TANK � � SEWER--LINES -- � � � DISPOSAL FLD. PROP. LINE � `{ F FOUNDATION *Y OTHER WELL PITS/SUMPS AGRICULTURE-WELL. _, INTENDED USE TYPE OF WELL PRO13LEM AREA CON STRUCTION-SPICIFICATIONS e El Bottom ❑ Manteca Dia- of Well Excavatio y Dia. of Well Casing l ❑ Industrial p p Type of Casing - -Specifications ❑ Domestic/Private ravel Pack ❑ Tracy g '� l- ', _ n Other Cl Delta Depth of Grout Seal 7-017 -,%Type o Grout I ! Irrigation Approx. Depth I 1 stern Surja�a Seal Installed by lState Work Done_ t• Repair Work Done Type op H.P. t Re ❑- Tf Pum — '� p i � Well Destruction ❑ Well Diameter Sealing Material trop 50'7 Depth Filler Material 18elow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION t 1 REPAIR/ADDITION l 1 DESTRUCTION I 1 1No septic system permitted it public sewer is t available within 200 feet.I Installation will serve: Residence I Commercial_ Other t ' Number af,living units: Number of bedrooms Water table depth Character of soil.to a depth of� feet: f SEPTIC TANK 4 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PCT'O Method of Disposal 4 Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No._& Length of lines= Total length/size .r FILTER BED ❑ Distance to nearest: Well Foundation Property Line �,- �+ N ~ f j SEEPAGE PITS 1 I Depth - Size umber ''�; V SUMPS ❑ Distance to nearest: Well Foundation ` Property Line DISPOSAL PONDS ❑ �`` 1 hereby certify that I have prepared this application and'ththe work will be done in accordance with San Joaquin county ordinances, state laws, ands rules and regulations of the San Joaquin local Health Dist t. ' Home owner or licensed agent's signature certifies the�fcllowing: "I certify that"in.th;b�performance of the work for which this permit is issued, I shall not, t to workman's•compensatiion laws of California."Contractor's hiring or sub-contracting signature employ any person in such manner as to become subjec 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; /1 tion laws of California." ` s,. The applicant must call for all required inspections. Cc late drawing,o�reverse-side. tW, ,� , l Signed X TitW Date: + FOR DEPARTMENT USE ONLY }r n f rl! Application Accepted by �`_ r` - Date Area tii Pit or Grout Inspection by c Date L Final Inspection by date ' h Additional Comments: no ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Trac 835-6385 ' " Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O-.,,Box 2009, Silk., CA 95201 r FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED,By DATE PER ND. INFO CASH `� r * + EH 13-24(REV.t/Hsf 's EH 14-2e