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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 1 YEAR FROM DATE ISSUED I (Complete in Triplicate) I 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 � City Lot Size �LL �!f,S PM .fob Address / � li p Owner's Name Address 's ' v �® Phone 7 License No. Phone ^' Contractor i�"'f't''�'�dr-�' � Address TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMEN DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM.-RE?AI �"OTHERel7 ��¢Q .DISTANCE TO NEAREST: SEPTIC TANK _/AL1 f SEWER LINES —;XISPOSAL FLD. t ,PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ �d INTENDED USE TYPE OF WELL PROBLEM AREA ..CONSTRUCTION SPECIFICATIONS ❑ Open Bottom EDManteca Dia: of Well Excavation + Dia o e asingt s F-1Industrial r Ll p ❑ Domestic/Private Gravel Pack[ Tracy Type of Casing Type of Grout — f`l Public [_1 Other ❑ Delta Depth of Grout Seal yp I Irrigation �..Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump it�J N,r H.P.—��_-- State Work Done Well Destruction ❑ Well Diameter Sealing Material (tap-50,)--" Depth Filler Material (Below 501 � } 1 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION I 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:` Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ - �, i 0 (Method of Disposal t. "�" �" - .N-�..��*^.r�Pro ert tine----"�""..,` - Distance to nearest: Well Foundation P y " j Ff LEACHING LINE ❑ No. & Length of lines Total length/size - ---..r.w•.� FILTER BED ..-- -C-I. -Distance"to neatest: Well` Foundation Property Line r SEEPAGE PITS l I Depth Size Number SUMPS ❑ Distance!to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ C ill be done in accordance with San Joaquin county ordinances, state taws, and I hereby certify that I have prepared this application and that the work w a 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 r sub-contracting signature employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring a 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 f The applicant must calf for all required inspection Complete drawing on reverse side. Signed X Title: Date: FOR DEPARTMENT U E ONLY �q DArea Application Accepted by ate 1J��,!., Final inspeDatey /�/� Date ction b - Pit or Grout Inspection by 47 Additional Comments: i f ❑ Silk 466-6781 ❑ Lodi 369421 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Silk., CA 95201 .1 ` FEE AMOUNT DUES AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT'NO. INFO J.v-ya3 r . EH 13.24(REV.I 5f Lg�- a EH 14-26