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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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�.r / -__ Job Address �t e 70 Z /nu �f�GC/P/^ �Q- 4 City �1�/ Lot Size Aere. C. PM Owner's Name .f�* ��1w/ cLpf^ Address Phone Contractor -zr v^ Addres IrLicense No. Phone Z-7G, TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES f DISPOSAL FLD�_�PROP. LINE FOUNDATION/h90--if AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION yc/ ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation d Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of CasingSpecifications Public Ll Other`' Ll Delta Depth of Grout Seal Z Type of Grout _ X Irrigation _Approx. Depth 11 Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. 5 State ork Done Well Destruction Well Diameter AyfSealing Material Itop 501 _ A Depth Filler Material (Below 50') (� TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is )� -- a available within 200 feet.) Installation will.serve: Residence_ Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 316-610 _ Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 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 '-N, SEEPAGE PITS 11 Depth Size _ Number SUMPS Ll Distance to nearest: 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 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." The applicant mus all for all required inspections. Complete drawing on reverse side. Signed X-__- _ -cam- Title: _ -Date: _ FOR DEPARTMENT USE ONLY Application Accepted b tate Weg Area Pit ar,GroGt Inspection by1 I t Date y � Final Inspection by — _ Date ! Additional Comments: Old 411N 4V n C del r ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca $23-7144 ❑ Tracy 835-6385 �7�y� Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 '50 �.20 FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY D�A�TEp PERMIT'NO. t EH 13-24{qEV.t i fl 51 ry Vk� EH 14-26 7/ti 9 Sy s9-17c l