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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED II (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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District �lll Job Address75� itw�� City Lot Size PM Owner's Name Address �sfs3 �ticcs �� Phone '7W4-vT �-�r•� �Js 3 Cor:tract Address0yoloc License No- g��['hone ^ � TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ L. PUMP INSTALLATIONOC SYSTEM REPAIR'❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER-LINES,-F --:.D15P05AL_FLD. - -" PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PIS TS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS a ❑ Industrial' ❑ Open Bottom ❑ Manteca .-'Dia. of Well Excavation Dia. of Well Casing O Domestic/Private ❑ Gravel Pack --❑-T-racy Type of Casing Specifications (l Public Cl Other Ll Delta. Depth of"Grout Seat Type of Grout __. f/� I I Irrigation _'hApprox. Depth l I Eastern r `;o urface Seal Installed by Repair Work Done ❑ Type of Pum 1/ p yp p H.P.` �' State Work pone Well Destruction ❑ Well".Diameter .Sealing Material (top 501 Depth Filler,Material (Below 501 TYPE OF SEPTIC WORK; NEW INSTALLATION I 1 REPAIWADDITION 1 I DESTRUCTION I k {No septic system permitted if public sewer is " it { available within 200 feet.) Installation will serve: ;Residence Commercial_ Other Number of living units: Number of bedrooms - r Character of soil to a depth of 3 feet: 'r Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments,- PKG. ompartmentsPKG. TREATMENT PLT. ❑ Method of-Disposal Distance to nearest: Well Foundation Property Line ' r♦ t V ori � L LEACHING LINE ❑ No- & Length of lines Total length/size v f FILTER BED ❑ Distance to nearest: Well' Foundation Property Line....,. SEEPAGE PITS 1 1 Depth Size " Number VL" ❑-'Distance-to nearest: -Well - f=oundation 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 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 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 m a i for all rl,quired inspections. Complete drawing on re arse side. Signed Title. v Data: FO EPARTMENT USE ONLY Application Accepted b ,2/ y Date_. � — '� Area Pit or Grout Inspection by Data Final Inspection by Date C�A'eq :I Additional Comments: ❑ Stk 466-6781 ❑ Lodi,i 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 ! Applicant - Return ail copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., 'P.O. Box 2009, Stk., CA 95201 al - FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. -EH 13-24 u1EV.1 i n E0 EH 14-2a it