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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 ; :I 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 �7 ,-13_%"_R_ �,C#rA� k�� Cid, E 'Lot Size _ PM _ r Owner's Name Addre - Phone Contractor & ;Address License Na. Phone i TYPE OF WELL/PUMP:__ .� , NEW WELL,El _ w . --WELL REPLACEMENT O DESTRUCTION El PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 4 f DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. I PROP. LINE !' FOUNDATION AGRICULTURE WELL OTHER WELL PETS/SUMPS ;�-INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I Q.Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation s Dia. of Well Casing w, ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications O Public ❑ Other . ❑ Delta,; Depth of Grout Seal Type of Grout j ' [_1 Irrigation JApprox. Depth ❑ Eastern �.4 Surface Seal Installed by Repair Work Done ElType,of Pump H.P.` State Work Done a Well Destruction ❑ Weft Diameter Sealing`Material (top 50'1 :I Depth Filler Material (Below 501 _. YPE OF SEPTIC WORK. NEW INSTALLATION p -REPAIR/ADDITION. "DESTRUCTION [I (No septic system permitted if public sewer is havailable within 200 feet,J Installation will serve: Residence4f1 Comore cial' Other - �' Number of living units:--,,It Number of bedrooms ' s ICharacter of soil to a depth of 3 feet: } ° Water table depth �� ## • ' SEPTIC TANK �fype/Mfg - t Ca aaci t r `' t :IH p ty� � No. Compartment's 7- PKG. TREATMENT PLT. ❑ " " Method of Disposal t E i Distance to nearest: Well 1` Fbunaation+ property Line ,I EACHING LINE r-❑ --No. & Length of fines Total length/size f '� FILTER BER a�'� p"pistance#o neatest:" We11` Foundation Property Line SEEPAGE PITS' ❑ Depth Size Number l I SUMPS � ❑ Distance to nearest: Well Foundation Property Line ' �" ,•' (,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 Ip p , Pp 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 mai er 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,1 shall employ persons subject to workman's compensa- Fon laws of California." The applicant t all fo 11 requ' inspections. Complete drawing on reverse side. s l IIM I _ Signed Title: t Date: { 1- FOR DEPARTMENT USE ONLY Q p Application Accepted by r j bate—A-9`�C?� Area i Pit or Grout Ins on.b Pe Data J Final Inspection by IL Date Additional Comments: Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-5385 S 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 CK RECEIVED BY CASH DATE PERMIT"NO. •, +EH t3!241REv,tie 51 a EH t4128 '