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` APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 `PERMIT EXPIRES 1'YEAR FROM DATE ISSUED l f!1 (Complete in Triplicate) Application is heiehy made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is rlty Ordinance No.549 for sewage or No. 1B62 for well/pump and the Rules and Regulations of the San Joaquin made in compliance with San Joaquin CoI Local Health District. f � i ' �� f" Cit Lot Size PM Job Address �_.. { Owner's Name _ "'�^' Address Phone C_ a �` iv Contractor +-� Address License No. Phone as TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT-1-1DESTRUCTIONLl PUMP INSTALLATION ❑ SYSTEM"REPAIR� OTHER Ll DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing ❑ Industrial Ll Op., Bottom ❑ Manteca Dia. of Well Excavation� S Specifications Vpomestic/Private ❑ Gravel Pack Ll Tracy Type of Casing p - ('l Public ❑ Other F1 Delta Depth of Grout Seal Type of Grout —. I I Irrigation -Approx. Depth I 1 Easternju.rf-aea Seal Installed by - Repair Work bone � Type of Pump H.P. 3��6 - State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 �- Depth A Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION i'I REPAIRIADDITION I I DESTRUCTION 4 I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial— Other Number of living units: -Number of bedrooms Character of soil to a depth of 3 feet: t a Ept ?' ` iCapacitACompartments ❑ Type/MfgSEPTIC TANK .� PKG. TREATMENT PLT. ❑ •,� ►► _�_ Meth �I f�p s I Property ropert Lia" ''" �� Distance to nearest: Well. �. •-- Foundations""'--- Y t LEACHING LINE ❑ No. & Length of lines Total length/ f FILTER SED El Distance to nearest: Well �� Foundation Property EWI TU�Fc` �-- a __ t SEEPAGE PITS I 1 Depth 1 Size _ Number R SUMPS D Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ a 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." r The applicant mus c li for all req ired inspections. Complete drawing on reverse side. ; � Signed Title:J.dZA Date: FOR RTINENT USE ONLY I 07ej 216 ter' a-•Yo-.s : r••,� / � Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date t � Additional Comments: ❑ Silk 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. BoCK x 20095tk., CA 95201 FEE ;AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT'NO. LJJEH 13-24(REV.1i n sl V" ��. . ��^�-�r• F •`l I9C EH 14-26