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I APPLICATION-FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE`T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED a -in tel�,WQa :fi rt'. «i "�`��; „(Complete in Triplicate). Application is hereby made to the San Joaquin Loral 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,sawage or No. 1862 for wail/pump and the Rules and Regulations of the San Joaquin Local Health District.:1L��" Job Addressf/a F — City Lot Size PM - - Owner's Name- - � .- Address " (2� .�� r11�' Phone ` Contractor's Name ' License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR L7 OTHER Ll DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 4 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f ❑ industrial CJ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack .❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by_ Repair Work Dane ❑ Type of Pump I H.P. State Work Done s Well Destruction ❑ Well Diameter Sealing Material {top 501 Depth t Filler Material (Below 50') i TYPE OF SEPTIC WORK: NEW INSTALLATION ElREPAIR/ADDITION ❑ DESTRUCTION ❑ (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.- "A ! Water table depth SEPTIC TANK _ i❑f(Type/Mfg 1 Capacity _ No. Compartments PKG. TREATMENT PLT. 71 Method of Disposal ''distance to nearest: Well " I -I _ Foundation Property Line 1 LEACHING LINE ❑ .No. & Length of lines — Total length/size FILTER BED" "'❑ 'Distance to;nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS El' Distance to nearest: Well Foundation Property Line DISPOSAL PONDS _ ❑ i 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: '9 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 ernploy persons subject to workman's compensa- 'tion laws of California." # The applicant must call for all required inspections. Complete drawing on reverse side. Signed X &20LL Title; , � re�✓ Date:"- FOR DEPARTMENT USE ONLY Application Accepted by � r Date Areay Pit or Grout Inspection by DFinal Inspection by Date D4 Additional Comments: , ❑ 5tk 466-6781 0 Lodi 369-3621" t" Manteca 823-7104 y El Tracy 835-6385 _ r Applicant- Return all copies to: Environmental ealth Permit/services 1601E. Hazelton Ave., P.O. Box 2009, Stk.r CA 95201 } r FEE 'AMOUNT DUE ; AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO t EH 13-24 IREY.10/831 , EH 14-28 i L