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I . � APPLICATION FOR PERMIT 0' � SAN JOAQUIN LOCAL HEALTH DISTRICT � 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 II 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 ' "''F'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. City Lot Size PM ,!Job:Address -Z-ANE Owner's Name Addressfi ..2!'�►L[]� Phone L � I� rPhon Contractor Address ► 1 License K TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT LJ DESTRUCTION ❑ PUMP INSTALLATION D 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 ❑ Industrial t El Open Bottom 1-1MantecaDia- of Well Excavation Dia. of Well Casing Gl e Domestic/Private ❑ Gravel Pack: ❑ Tracy 9 Specifications i`l Public �i Fl Other r Type of Casing n Delta Depth of Grout Seal Type of Grout T I I Irrigation .! Approx.-Depth I I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destructioin ❑ Well Diameters Sealing Material (top 501 il!". Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITIONDESTRUCTION i I (No septic system permitted if public sewer is I� available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: : Water table depth SEPTIC TANK ❑ Type/Mfg I Capacity No. Compartments PKG. TREATMENT`PLT. ❑ ! Method of Disposal SS Distance to nearest: Wel! Foundation Property Line ;t ] •'LEACHING LINE ❑ No. & Length of tines Total length/size FILTER BED ❑ Distance tc nearest: Well Foundation Property Line s SEEPAGE PITS Depth Size _-�f� Number SUMPS II L1 Distance to nearest: Well� Foundation A'' Property Line /Of 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 P' y rules and regulations of the San Joaquin Local Health Dif trict. 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." The applicant)must call for all requiredin tions. Complet drawing on reverse side. 4 Si ned Title: Date:1 9 _ i FOR DEPARTMENT USE ONLY J�'"�� Date Area Application�Accepted by ki f Pit -Grout Inspection by Date �2 Z�`, Final Inspection by` L G Date ."(Lit-91 I� Additional Comments: El 5tk 466-6781 ❑ Lodi 369:3621. ❑ Manteca 823-7104 171Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO, INFO GASH [ +.EH 13-24{REV.t/x 51 f o 1 -fir may-Z�� EH 14-29 l I r