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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 j (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 istrict: F Cit / Lot Sized [J PM Job Address � � � «� y 11 Owner's Name t Address 1 7 �c5� � �trf a``c -24,k11? Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIO PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEMAREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing Specifications �} (`I Public (7 Other F1 Delta Depth of Grout Seal Type of Grout _ I I irrigation __.Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done— ❑ Type of Pump I H.P. State Work Done Well Destruction C1 Well Diameter Sealing Material /top 50') r. Depth l Filler Material (Below 50'1 -- TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION I I DESTRUCTION (No septic system permitted if public sewer is r 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. ❑ € J Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance tornearest: Well Foundation Property tine I SEEPAGE PITS l I Depth I Size Number SUMPS Cl Distance toynearest: 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: "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 thi ermit is issued, I shall employ persons subject to workman's compensa- tion laws of California." I4 The applicant must call for all required inspections. Complete drawing on reverse side. _! s��-,ryy Title: —J Date: ! ✓` 8 Signed X _- - ---- FOR DEPARTMENT USE ONLY I1'la"Z& t Application Accepted by pate ` Ar Pit or Grout Inspection by Data Final Inspection by Date 20 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ` ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environrt 91 tal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, S1k., CA 95201 3 �\ 1 FEET AMOUNTE AMOUNT REMITTED CK 4 CASH RECEIVED BY DATE PERMIT'NO. INFO 00 3-241REV.iix5� O C__JS 14 EH 26 'S a r