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APPLICATION FOR'PERMIT- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 1209) 466-6781 PERMIT EXPIRES I 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 o 7 City Lot Size PM • I ^r` Owner's Name _ t Address E PhoneW Contractor's Name ( t�lfse No. 13 Phone } i TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ W PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Q DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE V 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 Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P:-^--' -- State Work Done--� Well Destruction ❑ Well Diameter Sealing Material (top 501 I Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ Mo septic system permitted if public sewer is (� available within 200 feet.) �+� Installation will serve: Residence Commercial_ Other Number of living units: _J_ Number of bedrooms 3 Character of soil to a depth of 3 feet: K Water table depth SEPTIC TANK ❑ Type/Mfg If ICapacity No. Compartments PKG. TRLATMENT PLT. ❑ Method of Disposal + t Distance to nearest: Well Foundation Property Line e LEACHING LINE * No 1ength of lines Total length/size ------ FILTER FILTER BED ❑ Distance to nearest: Well Foundation Property Line i1 w. SEEPAGE PITS Depth _Size k. Number i SUMPS ❑ Distance to nearest: Well� r Foundation !ZID Property Line DISPOSAL PONDS O %I-h1! _t A _.—A 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." M its—I a1-r .,— The applicant us 11all req inspections. Complete drawing on reverse side. Signed '7Title: �ai1Date: r �.-�"d '� ' tc FOR DEPARTMENT USE ONLY A Application li . cccepted byArea � b :� �il — C� " Date�___.. Pit or Grout Inspection by Datel Final Inspection by Date V ditional Comments:tk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 EITracy 835-6385 pplicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK# RECEIVED BY DATE PERMIT`NO. INFO CASH Q D : + EH 1241REV.10f831 "��,(J _ O V o EH 144-26