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it APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 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. F. ; &,- r WWI Job Address City Lot Size Z� X�-0 PM Owner's Name ` Address Phone�.��``"i � Contractor's Name 6License Na. Ty `Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION_❑ . PUMP.INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ \. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESr DI POSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation-1 Dia. of Well Casing i ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ~� Specifications ❑ Public ❑ Other. ❑ Delta Depth of Grout Seal �'f: ,Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface,Seal Installedbyr ' Repair Work Done ❑ Type of Pump H.P. State Work Done j j R ' Weil Destruction ❑ Well Diameter Sealing Ma a ial (tp'50') Depth Filler Material.(Below 501 i r TYPE OF SEPTIC WORK: NEW INSTALLATION ElREPAIR/ADDITION DESTRUCTION Ll (No septic system p*mitted if public sewer is 1 available within 200 feet.) j Installation will serve: Residence__Commercial ,Other f ` q A � Number of living units,—4c Number of bedroo s ,a Character of soil to a depth of 3 feet: �_J ` Water table depth SEPTIC TANK i❑ Type/Mfg Capacity No. Compartments , PKG. TREATMENT PLT'❑ ;q' Method of Disposal Distance to nearest: Well Foundation Property Line 4-1 LEACHING LINE-7 j 'X.No. & Length of lines -� Total 14ngth/size!' 0 2- FILTER BED Well Distance to nearest: Well Foundation .._>� Property Line- g SEEPAGE PITS �4 "Depfh """ Size v ------Number•`r t + f'� SUMPS �"" L] Distance to nearest: Well/ � . Foundation - Prcperty`Line^ � DISPOSAL PONDS i❑ I hereby certify that I hale prepared this application and that the work will be done ih accordance with San Joaquin county ordinances state laws, and rules and regulations of the San Joaquin Local Health District.- 44 - Home owner or licensed agent's signature certifies the following: "I certify that in the performance'of the work for which this perrili``is•issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Cont'ractor's hiring or,.uXbontracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued;_I'shall•employ-personssuhject to workman's tcompensa- tion laws of California." i 1 ... .•' _ ` The applicant must call for II req/uir ins ctiona. Complete drawing on reverse side. r ,�.. Signed l� Title: ` t Date: " f� i \ FOR DEPARTMENT USE ONLY tl F i Date !,2— rea �l Application Accepted bye` ± Pit or Grout Inspection by ate o2 Final Inspecctiion by D Additional Comments =-' ' (y C - ❑ Stk 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, Stl , CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT`NO. INFO CASH + EH 13-24(RE57"10783)'"��'" ,,_�. : ..: :•.� .- c' s �q S EH 1426 1 1 i