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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 11601 E. HAZE T ON 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. Lot Size�'�`L-` PM Job Address tf - Address Phone Owner's Name t {. ) ~ }� License N6�S1S32 Phone CJ .Contractor Address, __—.- TY _ OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER Q DIS'ANCE TO NEAREST: SEPTIC TANK S SEWER LINE DISPOSAL FLD. - PROP. LINE ` FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS 1-. INTENDED USE TYPE-OF-WEL•L-^ --PROBLEM AREA .-.CONSTRUCTION SP.ECIFJCATIONS - " DI----- --Well Casing . ❑ Industrial ❑ Open Bottom - D.Manteca Dia. of Wefl Excavation [] Domestic/Private 0 Gravel Pack 1-1Tracy Type of Casing Specifications t# Cl Delta Depth of Grout Seal Type of Grout -. 17 ` ❑ Other l'1 Public I I Irrigation —.Approx. Depth I ] Eastern Surface Seal Installed by { i H P. ; State Work Done Repair Work Done ❑ Type of Pump. _ F Well Destruction ❑ Well Diameter,' # Sealing Material (top 501 't Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION EPAIR/ADDITION l DESTRUCTION I I (No septic system permitted it public sewer is ,1 1. 1 available within 200 feet.) t � Installation will serve: Residence corrrmercill— Other, i , Number of living units: ,Number of be7dr�oorsl * C Water table depth' Character of soil to a depth of 3:feet:" ` SEPTIC TANK TypelMfg G r Capacity _�o...Compartments,,. l ? PKG. TREATMENT PLT. Method of Disposal 1-1 � - I r f- Distance to nearest: Well s�CO V--Foundation 0 Property.Line f -- cfd Tuotal length/size LEACHING LINE No. & Length of lines T ' 4 Foundation; Jf Property Line FILTER BED ❑ Distance to nearest: Wella&—..� SEEPAGE PITS / Depth _ - Size - Number /rt.�� Line SUMPS� `ham. 3 L1 i Distance to nearest: .._WeII - Foundation /© �" �-_ Property � PONDS ❑� "`-'� 11 I hereby certify-t at 1-ha.e..p.wpated_this:application and that the work will be done in accordan` a with,San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local'Health-D3trict. Home owner or licensed agent's signature certifies the following: "l certify•that_in 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-Cilifornia:__Contractor's hiring or sub contracting signature certifies the following:"I certify that i'the performance of the work for which this permit is issued, I shall empty persons subject to workman's compensa- tion laws of California." The applicant st; 11 far a required'" pections. Complete drawingon reverse side- - s Date- FOR Signed X # 'Title: Data: * t - FOR DEPARTMENT USE ONLY10 .-. i s Date v� Area Application Accepted by Pit or Grout Inspection by 3 Date _ Final Inspection by f' Date 7/7-�'� Additional Comments:, ❑ Stk 466-6781 'D Lodi 369-3621 ❑ Manteca 3-7104 ❑ Tracy 635-6385 r Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTEDG KSH RECEIVED BY OATS PERMIT NO. INFO ('� r n`i +.EH 13-24(REV.r/M 5) 9d �} EH 14-26 k