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APPLICATION FOR PERMIT •J SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE�TON AVE., STOCKTON, CA I Telephone (209) 466-6781 .PERMIT EXPIRES 1 YEAR FROM DATE ISSUED l (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:i2 srp h" pf rq,G;vE�- Ods- �3a: 06 L®fie`.. . 11Z �„e Jab Address �-+�r , City Lot' Size C� f�7 PMS/ Owner's Name d`L�'� Address ; \ h� onV `dt`/`� Contractor W { ��I y� Address 7 VfOLicense No. ��y� Phone9�� 6 —I�•J TYPE OF WELL/PUMP: I.NEW WELL ,J WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 171 DISTANCE TO NEA E T:-SEPTIC.TANK.'' SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION'' I AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO I XI A. 0 Industrial L] Open Bottom LII Manteca Manteca Dia. of Well io Dia. of Well Casing 14 VArJ ❑ Domestic/Private A Gravel Pack ❑ Tracy Type of Casing fVC i Specifications ❑ Public ❑ Other i` ❑ Delta Depth of Grout Seal rJ # Tx g of Grout / y Irryi �tiorl �4pprox. Depth ❑ Eastern Surface Seal installed by H ' ►rr 1 !A Repair Work"Don5 ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 YPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation rve: Residence_ Commercial_ Other f Number of living units: ` ' Number of bedrooms E Character of soil to a depth of 3 Water table depth SEPTIC TANK ❑ Type/Mfg: Capacity No. Compartments PKG. TREATMENT PLT. ❑ r Method of Disposal Distance toinearest: Well oundation Property Line J I - LEACHING LINE ❑ No. & Length of lines �Ienglh/size FILTER BED ❑ Distance to nearest: Well Foundation F ' SEEPAGE PITS ❑ Depth Size Number SUMPS..,,, ❑ Distance to nearest: Well Foundation Property Line OISPOSALI 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. I 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 applican ust calf r all r quired inspections. Complete drawing on reverse side.. Signed Title: erT� C7� Dater' F R DEPAR IVT USE ONLY I" Application Accepted by Date r Area Pit or Grout Inspection by Date Final Inspection by Date {. .. .- Additional Comments: . SY LrJvC./ Qc- ❑-Stk 466-6781 ❑ Lodi 369-3621 ❑ Mant a23- 04 ❑ Tracy 8W6385 e Applicant- Return all copies to: Emiironrrental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT*NO. INFO + EH 1324 1REV.1/e 5) Eli 1428 �Q" �� •,.