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APPLICATIONFOR!'PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 w 'PERMIT EXPIRES T YEAR FROM DATE ISSUED (Com lets in Tri licatel 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 thb Rules and Regulations,of the San Joaquin Local Health District. . Job Address 1 City Lot Size PM. Owner's Name Address _ Vvi, Phone _ T 1 Contractor's Name License No. <) Phone z(ter; — TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATIOIVE1 SYSTEM REPAIR ?< OTHER ❑- DISTANCE TO NEAREST: SEPTIC TANK — 1_& _ SEWER LINES _ - DISPOSAL FLD. PROP. LINE FOUNDATION / AGRICULTURE WELL -- OTHER WELL # PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom _- ❑ Manteca Dia. of Well Excavation Dia. of Wall Casing- �Domestic/Private., 13 Gravel Pack 1-1 Tracy" Type of Casin ❑ Public ❑ Other ta ❑ Dg Specifications Delta Depth of Grout Seal 1 1 El Irrigation Type of Grout pprox, Dth ❑ Eastern rface-Seal Installedby I r Repair Work Done Type of Pump I H.p f j"r w State Work Done E.. —V1 } i 41g'02 Well,Destruction ❑ Well Diameter I.Sealing Material (top 50')! `r � r' r� Depth } Filler Material (Below 50') ;b, 0 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITIONk 1: DESTRUCTION ❑ (No septic system permitted if public sewer is Installation will seavailable within 200 feet.)rve: Residence_ Commercial_ Other r Number of living units: Number of bedrooms :( Character of,soil to a depth of 3`feet: r g t f _Water table depth c SEPTIC TANK ❑,.:,.Type/Mfg V Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line y LEACHING LINE- ❑ No. & Length'of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS„ ❑ Depth 4 Size1 Number i"%t` SUMPS ❑ Distance to nearest: Weil Foundation Property Line r �. DISPOSAL PONDS ❑' 1 hereby certify that Vhave"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 ap nt m t call for all requ' tnspe ns. Complete drawing on se side. 1.. Ke}( Signed Title: _ Date: r FOR DEPARTMENT USE ONLY } Application Accepted b Date Area {� Pit or Grout Inspectio Date Final Inspection by Date d { Additional Comments: 4/1 ❑ Stk 466r67810 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copjas.to: Environmental Health Permit/Services 1601 E. Hazekon Ave., P:_O.-Box 2009, Stk., CA 95201^ FEEaT DUE f AMOUNT REMITTED T `CK RECEIVED 8Y INFO CASH DATE PERMIT'NO. } _+ EH 1&24(REV.1D/ffi) - r i