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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T OIC AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES T 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. 1662 far well/pump and the Rul��nd�Regulations t0�n Joaquin Local Health District. ''��,,CCrr } Si t Lot Size � Q� PM .'(� f1-7-=l✓:. t City . Job Address 1 - , Phone ��L/— ZZ Owner's Name f '1ZCLi: Address &7 License No � �Z ZCc Phone��-.S�QS� Contract Address ` — NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ' TYPE OF WELL/PUMP: OTHER ❑ ` PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ v E SEWER LINES �� DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK - PITS/SUMPS �s FOUNDATION `'""AGFi1CULTURE WELL _ OTHER WELL x INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing 1\ ❑ Industrial -❑ Open Bottom 171 Manteca Dia. of Well ExcavationA Specifications ❑ Domestic/PTivate LJ Gravel Pack El Tracy Type of Casing I-1 Public ❑ Other Delta Depth of Grout Seal Type of Grout — f �_Approx. Depth I l Eastern Surface Seal Installed by r I I Irrigation State Work Done Repair Work Done ❑ Type of Pump H.P. c._. Well Destruction ❑ Well Diameter Sealing Material (top 501 I Depth Filler Material (Below 50') ' I TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I ! DESTRUCTION { septic system within 200 f:etltfed if public sewer is Installation will serve: Residence_e Commercial Other fi ' Number of d o l �-' Number of living units: rs ;!Nater table depth f Character of soil to a depth of 3 feet: 1, T el Mfg CapacityNo. Compartmerrts SEPTIC TANK YP Method of Disposal PKG. TREATMENT PLT. ❑ 1 11. Foundation Property Line ». Distance to nearest: Well — � -- ,/ ! X` No. & Length of lines R Total length/size O LEACHING LINE ^ �" _ / O , _. � - FILTER BED ❑ Distance to nearest: �ell��--._ �%+�ation Property Line � f ' De th " n :,�t�=.: �F ;_•„ r SEEPAGE PITS SizeNumber p x f /+ Property Line 2 SUMPS L1 Distance to nearest: Well ..—`� Foundation1Z_— T T DISPOSAL PONDS ❑ � r Y plication and that the work will be done in accordance with San Joaquin county ordinances, state laws, and I hereby certify that I have prepared this ap rules and regulations of the San Joaquin Local HealtFi�District. 1 ertify that in the performance of the work for which this permit is issued, I shall not Home owner or licensed agent's-sigf ature-certifies-the following:.1.c employ any person in such ma nn er as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies`the followin "l ce Mify that in the performance.of.the work for which this permit is issued,l shall employ persons subject to workman's compensa- 9: � tion laws'of,California� i The t, 11 fo�all r' it inspections.-Complete-drawing on re se side. I Signed X Title: r Date: it JC FOR DEPARTMENT USE ONLY Date "ZLj � � Area F 'k Application Accepted by Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: 4 �� ❑ Stic 466-6781 ❑ Lodi -3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 + Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 FEE CK RECEIVED BY DATE PERMIT NO. AMOUNT DUE AMOUNT REMITTED CASH INFO