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APPLICATION FOR PERMIT t 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. Job Address- Y '� "• City. Lot Size `PM Owner's Name CC, " `4%%F 11��TP � r�/�L Phone Contractor n ddress License No. - Phone - ^g. TYPE OF WELL/PUMP ,,INIW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTI,_=_R In DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES �- .DISPOSAL FLD PROP. LINE 4 „ FOUNDATION AGRICULTURE WELL --------OTHER WELL ��PITS/SUMPS INTENDED USE ; TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONP7j ❑ I`ndustriall� ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing .: omestic/Private Gravel Pack ❑ Tracy Type of Casing �� Specification f'1 Rtililic ;. .� s'❑ Other 171 Delta - Depth of Grout Seal Ian� Type of Grout i I 1 Irrigation �CR30pprox. Depth i I Eastern S rface Seal Installed by e� LWD A .A Repair Work Done ❑ -Type,;of Pump_ H-P. State Work Done r 'WeIE Destruction ❑ �Well:piameter�-- - - -- -Sealing Material trop 50') Depth- Filler.'Material•(Below 501 # TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDIT4ON l 1 DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) ! Installation will serve: Residence— Commercial— Other Number of living units: ' Number of bedrooms Character of.soil to a depth of.3 feet:. : + t. Water table depth SEPTIC TANK �4._ ❑; Type/Mfg _ N. y" Capacity N V No. Compartments I r PKG. TREATMENT PLT. C1 ter Method of Disposal v" Distance to-nearest""" Well ---Property,Line- --- - ----y+�'{�5 LEACHING LINE Cl No. & Length of lines Total length/size. k t FILTER BED ""ti ❑ Distance to nearest: Well Foundation Property Line I 1 R SEEPAGE PITS I I Depth k Size _ Number _ l SUMPS ❑ Distance to nearest: Well Foundation Property Line f1 DISPOSAL PONDS ❑ 's T ' 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, aitd_ rules and regulations of the San Joaquin L_ocal_Health,Di§trict _ r Home owner or licensed agent's signature certifies the following: I certif that in'the rformance of the work for which this ermit is-issued; I shall not employ any person in such manner as to become subject to workman's componsation`laws of California." Contractoes 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 compens t yC tion laws of California.' r I f r 4' The applica t quir r Complete drawing on rave eesida. ' rT , i Signed X Title: - . Date: �. - _ FOR DEPARTMENT USE ON i r pplication Accepted by -�t-� Data Area , k or rot Ins Date r ' Final Inspection b 4r- L Date Inspection by p y t Itional Comments: ,tk 466-6781 ❑ Lodi 369-3621 0 Manteca 823-7104 ❑ Tracy 835-6385 :ant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED. CASH'S RECEIVED BY"' ' "DATE PERMIT NO. JH 51 c3 �A� L ��Z�� v ; F/; cA o � Z