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APPLICATION FOR PERMIT - SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEITON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1YEA-R-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 I Local Health District. Job Address a _ �_ -{. City-S Ah) t"`'''Size PM ----Owner's Name, Address - Phone- i Contractor's Name L` E VDRL 1A 1\1&__LiGense No. s` -`l- Phone -) TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ :DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ` INTENDED USE TYPE OF WELL- $ PROBLEM.AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom„ —0-Manteca Dia. of Well Excavation Dia. of Well Casing 0 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing" + Specifications171' `f i a Public 11Other ❑ Delta Depth of Grout Seal ' Type of Grout i ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done I Well Destruction ,_ C1Well Diameter Sealing Material (top 54') ,,,;Depth _t Filler Material (Below 501 I j TYPE OF SEPTIC WORK;--�INEW INSTALLATION❑ REPAIR/AbbITION KL_49ESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.► Installation will serve: Residence <ommercial Other Number of living units: �� Number of bedrooms_ Character of soil to a depth.of 3 feet: o Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments i PKG. TREATMENT PLT. ❑' ' f..r�.r-. Method of Disposal le e Distance to nearest: Well Foundation Property Line SJ LEACHING LINE gLNb. & Length of lines �� T9tal length/size- FILTER ength/size FILTER BED ❑ Distance to nearest: Well !i C! Foundation l-4 Property Line �l - SEEPAGE PITS..- --•.•.•&,-6epth 2�,� 3- ------- --Number- -I— SUMPS - —SUMPS ❑ Distance to-nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 6 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 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 or sub-contracting signature cs 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 la f California." I The applican !ust call r a!I equir ins ctions. Complete drawing on r erse side., � 1 3 Signed � Title: /),IA1� Date. -0 FORD PARTMENT USE ONLY Application Accepted by" Date ' � Pit or Grout Inspection b Date T Final Inspection Date S /6` ZV Add'' nal Comm 1 k 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1 FEE AMOUNT DUE AMOUNT REMITTED # RECEIVED BY DATE PERM!T"NO. INFO CASH + EH 1428 SREV.10183) tM,5 iV�/ f-i—"o"f �p / y 11, J.,'