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F APPLICATION FOR PERMIT .� SAN JOAQUIN LOCAL HEALTH DISTRICT < 1601'E. HAZETON AVE., STOCKTON, CA x • 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 andlor'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. /00/ #6 ar' � t I Job Address �- Lot Size PM f _ Owner's Name. yf' � - Address —„ '�?�P �'� t i' Phone d Contractor dress 1 cense No. /27�15. PR.one r TYPE OF WE_L/PUMP: NEW WELL ❑ WELL REPLACEMENT--FlDESTRUCTIONt❑ PUMP INSTA-LLAT-ION-9 SYSTEM-REPAfR-© T-HER"©- -"'� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES * + ' b- DISPOSAL`FL'D: • PROP. LINE FOUNDATION AGRICULTURE-WELL - OTHER WELD-L--�+~ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICA/TIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of-Well Casing r C] Domestic/Private ❑ Gravel Pack ❑ Tracy < •Type of Casing-r '� Specifications (`l.Public ❑ Other ❑ pelta a Depth of Grout*S al/ Type of Grout---, I I Irrigation — Approx. Depth I I Eastern 'Surface Seal Installed by- 0 y Repair Work Done L7 - Type of Pump H.P. L f State Work Done Well Destruction ❑ Vtlell Diameter Se_`alirig Material ltop 50) �~ l Depth Filler`Material-(Below 50') I TYPE OF SEPTIC WORK: NEW INSTALLATION FT REPAIR IADDITION I. V DESTRUCTION I 1 INo septic system permitted it public sewer is {{ available within 200 feet.) Installation will serve:. -Residence�!_._ Commercial= Other s _Number of living units: � Num - 1 X Number of bad {� Charactef of soil to a depth of 3 feet: -Water table depth I �s SEPTIC TANK ❑ Type/Mfg Capacityl—UP No. Compartments f PKG. TREATMENT PLT. ❑ Method of Disposal I ` Distance to nearest: Well Foundation Property Line ��",; LEACHING LINE ❑ No. & Length of lines Total length/size 70 1 FILTER BED ❑ Distance, ornearest: Well Q Foundation �_ Property Line SEEPAGE PITS Il Depth10 Size ,rNrumber ` SU Ll Distance to nearest: Well Foundation Property Line II DISPOSAL PONDS ❑ 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."Contractors hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shallemploypersons subject to workman's compensa- tion laws of California." The applicant must call for all re re inspections. om to drawing on reverse side. Signed X ' Title: Date: FOR DEPA TMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by 4 � Date Additional Comments: _ ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY ATE PERMIT"NO. + EH 1324 MEV,i i H 51 EH 14-26, - - i