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Y.� APPLICATION FOR PERMIT + SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 t PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San.Uoaquin Local Health District for a permit to construct and/of 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. " Cit �7 � Lot Size _ �� PM Job Address J y Owner's Name ( � S Pf�G�- y r / G �� Address J�T`—T' �t L'L l Phone B` ' T��`O A ' C) Address License No. Phone Contractor - _ TYPE OF WELL/PUMP: NEW WEL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ t PUMP INSTALLATION SYSTEM IR ❑� OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICU E WELL � t OTHER WELL PITS/SUMPS ' INTENDED USE TYPE OF WELL PROBL EA CONSTRUCTION SPECIFICATIONS r ❑ industrial *�.`❑,Open Bottom ❑ tee Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private �,❑ Gravel Pack Tracy Type of Casing Specifications h'. I'1 Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout I i irrigation Approx. De h i I Eastern Surface Seal Installed by - Repair Work Dane ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Seali Material (top 50') Depth Material IBelow 50'I TYPE OF SEPTIC WORK:,,�,NEW INSTALLATION Ia REPAIR/ADDITION I.I DESTRUCTIONIVINo septic system permitted if public sewer is 14,.4tvailable within 200 feet.) j. 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 i .. SEPTIC TANK Type Mfg Capacity No. Compartments PKG. TREATMENT PLT. S "+ 1 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ "No. &Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth t-Size Number SUMPS 0 Distance to nearest: 11—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 rules and regulations of the San Joaquin Localf Health District. " Home owner olicensed agent's signature certifies the following: "t 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." I The applicant st call for it re red ins cti ns. Complete drawing on reverse side. y .I � 3 Signed X Title: Date: l I f FOR DEPARTMENT USE ONLY Application Accepted by date Area 4 R i Pit or Grout Inspection Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369.3621 ❑ Manteca 104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Se as 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. I INFO /1 CASH EH 13-24(REV.1/X5) 4:` EH 14-26 J - �+tL11111 ov. I V ry. f�