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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ` 1601 E. HAZEL TON AVE., STOCKTON, CA Telephone {209} 466-6781 PERMIT EXPIRES 1 YEAR 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. Job Address d `��,� , (� City Lot Size PM Owner's Name e Address r d �'�€'V� Phone [ ►► aw[ Contracts Address TYPE OF WELL/PUMP: �.WLicense No." Fii,^,,ne NEW WELL �-�_._� �L REPLACEMENT ❑ DESTRUCTION ,� (. I PUMP'INSTALL4TION r '' SYSTEM REPAIR ❑ OTHER ❑ DANCE TO NEAREST: ,SERTI �NK (Q r' " SEWER LINES DISPOSAL FLD. +- � FOUNDATION > �-, PROP. LINE --s¢s� AGA'MULTURE WELL OTHER WELL--!45 PITS/SUMPS INTENDED USE TYPE*OF WELL PROBLEM AREA '-CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Opeit Bottom a Manteca Dia. of Well Excavation El Domestic/Private ❑ Graver Pack Dia. of Well Casing ❑ Public ❑ Tracy Type of Casing ❑ Other ❑ Delta Specifications Depth of Grout Seal ❑ Irrigation --Approx. Depth ❑ Eastern Type of Grout + Surface Seal Installed by O - Repair Work Done ❑ Type of Pump -��-- H p Well"Destruction Well Diameter State Work ne —�.�..—_.._" Sea ng Material-ftlop 5p') Depth t _.Filler Material„IBelow 50'} J TYPE OF SEPTIC WOR NEW INSTALLATION ❑ _RE PAI R/ADDITION LI pESTRUCTION ❑ (No septic system permitted if public sewer is 5 Installation will serve: Residence Commercial` available. 200 feet.) 011 Other Number living units Number of bedrooms ..... �' Characterr of soil to a depth of 3 feet: } SEPTIC TANK /' 1 E Type/Mfg — Water table depth PKG. TREATMENT PLT:❑ Capacity— No. Compartments = AE-., Distance to nearest: Well Method of Disposal Foundation Property Line LEACHING LINE ❑: No. & Length of lines FILTER BED r Total length/size 1 ❑ Distance to nearest: Well Foundation y I Property Line SEEPAGE PITS ❑ Depth iz SUMPS '.�r """�` Niimber ❑ Distance to nearest: V411-.� ,. .=FdIrn ation DISPOSAL PONDS ❑ Property Line F •�5 1 hereby certify that I have prepared this application Jnd 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 certifieihe following: f the work!for employ ane person in such manner as to become subject to workman's compensation lawsofCalifornia."nce Contractor's Ih ringch ,orr ublcont actngt is issued, lsignalture certifies the following:"t ce`ify that in the perfoiprlance of the work far which this permit is issued, I shall employ persons subject to vorkman's compensa- tion laws of California." The applicant must' ih for a re 'ed in tions. Complete drawing on reverse side. ' y Signed X Title: i Date: FOA DEPARTMENT USE ONLY Application Accepted by •••r Date ea Pit or Grout Inspection by Date ��_ i Final Inspection by Date C3 Additional Comments: ❑ Stk 486-6781 ❑ Lodi 369-3621 p Manteca 823-7104 ❑ Tracy 835.-6385 Applicant- Return ail copies'to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 �^ FEE AMOUNT DUE jA�MOEUINTREMITTEDNFOC RECEIVED 8Y DATE PERMIT'NO. EH 1324 fFIEV.t/a slEH 14.20 ®Q _7�L \ ^^ VI.,