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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT l 1601 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 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. ' Job Address /� 1 Z_1V City `Lot Size �� k j J PM Owner's Name Address Pflone Contractor's Name �.US License.No. O�' Phone- p TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑'' DESTRUCTION ❑ r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ _OTHER L7• : DISTANCE TO NEAREST: SEPTIC TANK! SEWER LINES DISPOSAL-FLD. PROP, LINE j FOUNDATION":' FAGRICULTURE WE(L OTHER WELLPITS/SUMPS . d INTENDED USE TYPErOF WETt' fi L PRO"BLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of-Well Excavation Dia. of Well Casing r ❑ Domestic/Private'" El Gravel Pack '❑ Tracy " Type of Lasing LZ Specifications b ❑•.Public_1` , _ ❑ Other ❑ Delta {Depth-of Grout Seal Type of Grout r,1 ❑.Irrigation .- Approx. Depth ❑ Eastern - --Surface Seal-Installed by v t Repair Work Done ❑ Type of Pump T—H.P. --State Work Done", N Well Destruction ❑ Well Diameter Sealing Material (top 50') -Z, Depth Filler Material`(Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION .DESTRUCTION ❑ (No septic system permitted if public sewer is N k' available within 200 feet.) r, Installation will serve: -Residence_X, Commerciai Other t . Number of living units: _J_ Number of bedrooms .-S Character of soil to a depth of 3 feet: Water table depth 4'� SEPTIC TANK Type/Mfg 3 Capacity �Z�a No. Compartments PKG. TREATMENT PLT..❑ Method of Disposal t Distance to nearest: Well �� Foundation Property Line��- �` F LEACHING LINE ❑ No. & Length of lines. '1 Total length/size ` FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth "' - Size . Number 3 SUMPS ❑ Distance to nearest: . Well Foundation' f Property Line DISPOSAL PONDS ❑ hereby certify that I have prepared this application and that thework 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 tKat 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 followi :'T6ertify that.in;, ,4� perfor nce of the-.work for which this permit is issued, I shall employ persons subject to"workman's compensa- tion laws of Caloo is" "'- ' -' , The applicant m II for all r icedions:, omplete drawin on re a side. ,. � Signed Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Are Pit or Grout Inspection by Date Final Inspection by f Date�,� Additional Comments: ❑ Stk 466-6781 0 Lodi 369-3621 ❑ Manteca 623-7104 0-Tracy'835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009„Stk., GAm%201FEE CK 0 y INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE �PERMIT'NO. + EH 13-24(REV.10/831 � -� y\ �+. �1 Q71L �1 1 O 1� EH 14-26 � 1