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ti APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application is he+eby 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 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. f Job Address / ' City Lot Size ao/9r- PM 4 F J Owner's Name S G `address ��1 'lF Phone Contractor Address License No Phone24/1 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ - PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industfiial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia" of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I f'] Public F I Other ❑ Delta Depth of Grout Seat Type of Grout �I I Irrigationr —_..Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑'. Type of Pump H.P. State Work Done _ Well-Destruction, ❑ Well Diameter Sealing+.Material (top 501 Depth Filler Material (Below 50') r TYPE OF'.S_E_PTIC ORI(: NEW INSTALLATION W- [ (.-DESTRUCTION I I (No septic system permitted if public sewer is / available within 200 feet.) JV Installation will serve: Residence Y Commercial_ Other Number of livirig units: Number of bedrooms Character ovoit to a depth of 3 feet: Water table depth SEPTIC TANK I3/Type/Mfg 0 Capacity No. Compartments 2— PKG. PKG. TREATMENT PLT. ❑ , Method of Disposal Distance to nearest: Well Foundation �D" - Property Line ops 7 f � ?� en th/size r LEACHING LINE LIF' No. & Length of tines RSG Total l g FILTER BED ❑ Distance to nearest: Well Foundation .24 � Property Line AD r � SEEPAGE PITS I�Depth ! Size�& Number ,SUMPS L-1 Distance to nearest: WeII�o�..S� Foundation :2 C2/ Property tine l 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."Contractor's hiring of sub-contracting signature r 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 applic t m call for all re ire inspections. Complete drawing on reverse side. I Sigrltd-x Title: 00,N) A-4 Date: t 4 i FOR DEPARTMENT USE ONLY } Application Accepted by � •I�J — ;Date dArea Pit or Grout Inspection by Date Final Inspectioy� Pu/J/t P Date '' Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 -- Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CKAI FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. + EH 1324 1 REV.I/N 51 EH 14"26 t� I SCJ o f Z s O �' 1