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APPLICATION FOR PERMIT SAN JOAQUIN ,LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA " Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR.FROM DATE ISSUED r pair•:; , r rl" (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 I� 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:., 7n' :�, 9 _ Y � PM Job Address — City Lot"Size Owner's Name �'� _ � °4`^ tit Address ,� ( 7 �� Phone ff -S /Q� Address 7 License No Z$Z 2�O Pfion Contrac4o DESTRUCTION ❑ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ , PUMP INSTALLATION ❑ SYSTEM REPAIR E3 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE ___—FOUNDATION--- -- -- - AGRICULTURE WEL-L-_OTHER-WELL -- ----PITS/SUMPS— INTENDED USE TYPE OF WELL PROBLEM AAEA� CONSTRUCTION SPECIFICATIONS EJ Industrial ❑ Open Bottom O'Nlanteca s Dia,-bf-W4,Ezcairatiori Dia. of Well Casing Type-of-Casin Specifications '"" "'-'O-Domestic/PPivate tTGrav�1-Patk"�^"'�Cl`Tracy-; 9""'T""�"'�"� ❑ Public ❑ Other ❑ Delta b Depth of Grout Seal Type of Grout ' ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ElType of Pump SHIP. + State Work Done 1. Well Destruction ❑ Well Diameter `Sealind Material (top'50') DepthIler Material.(Below X50') . TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRI DDIT16N OK DESTRI?CTION ❑ (No septic system permitted if public sewer is ii available within 200 feet.) "( Installation will serve: Residence Commercial t ether - t+ Number of living units: � Number of_ orns.�—�47 p D G Character of soil to a depth of 3 feet: µ� "- F Water table depth SEPTIC TANK ED Type/Mfg i� W --,Capacity— No. Compartments ' PKG. TREATMENT PLT. ❑ ', , Method of Disposal Foundation Property Line Distance to nearest:"lf Well i . ` LEACHING LINE 3 r L�N. Length of-lines Total length/size X f D _ /O Property Line s, FILTER BED ,v F ❑ oistance46--nearest: Well T Foundation SEEPAGE PITS �t�-Depth Size P Number 1 SUMPS ❑ Distance to nearest: Well«!r Foundation—ZOL— Property Line — DISPOSAL PONDS ❑ „ 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 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 st call for all quir inspections. Complete drawing on reve�s ', sSignedTitle: Date:i LL FOR DEPARTMENT USE ONLY i Application Accepted by Date Area Pit or Grout Inspection by Date a Final Inspection by Date Additional Comments: r ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Haielton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK HRECEIVED BYF. DATE PERMIT IVO. INFO CASH 7-lig + EH 13-24(REV.1/65) � �� EH 14-28