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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ` 1641 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 A made in compliance with San Jo'arquin 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 City ::! of Size PM 41 Owner's Namey-t .oa _ Phone e Contractor _Address L License No.•• 766�� Phone TYPE OF WELL/PUMP: ,,NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ (14 ;DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1� Industrial El NO Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Packs ❑ Tracy Type of Casing Specifications' F i'] Public r ❑ Other Ll Delta Depth of Grout Seal Type of Grout _ ,I I Irrigation r �IApprox. Depth I I Eastern Surface Seal Installed by i #Repair Work Done ❑ Type l f Pump H.P. State Work Done_ ,,Well Destruction f E) Well Diameter Sealing Material (top 501 1. 1 { DeptAlll Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION 1 I DESTRUCTION 1�1 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence��Commercial�� Other f a f Number of living units: �1! Number of bedrooms _ 4F t^ Character of soil to a depth ofIh3 feet: '# �'z - Water table depth SEPTIC TANK T>)pe/Mfg 1- ""'" ^Capacity d��— No. Compartments 'PKG. TREATMENT PLT. ❑ 1 t Method of Disposal i } Distance to nearest: Well -`Foundatio"n .._� Property-Line F LEACHING LINE Ni. & Length of lines T �T&t l Ieng-thlsize �~ r -. FILTER-BED ❑ Distance to nearest: Well oundation } r � Line-9495 � Property Line � Fr7__ SEEPAGE PITS i Depth t, F SM. , Number--;3 SUMPS/y L7 Distance to'nearest.: "` Well_ Foundation Property Lines,L��~ DISPOSAL PONDS ❑ 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, and rules and regulations of the Sani oaquin Local Health District Home owner or licensed agent's signature certifies the fallowing: "I certify that in the performance of the work for which this permit is issued, I shall not . employ Ir p y an y person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contractirig 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.' I� ! The applicant must call for all req 'ad in etions. Complete drawing on reverse side, ` e _ I v Signed X Title: Date: f O'er FOR DEPARTMENT USE ONLY i Application Accepted by r Date.41 " � Area v i / � Por Grout Inspr#ction by I Date6 Final Inspection by DateY t Additional Comments: !� ❑ Stk 466-6781. ❑ Lodi '11369-3621 ❑ Manteca 823-7104 ..❑ Tracy 835-6385 iApplicant - Return all copies to:i nvironmentel Health Permit/Services 1601`E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 < 11 INFO A�MODU�yNT`I DUE � AMOUNT REMITTED'' SASH ' � RECEIVED BY T DATE'� 'pEF1N117'NO' +.EH13-24tREV.tiwSt -EH 14-26