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r_ APPLICATION FOR PERMIT a II SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 I� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED II. c (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. ,, Y7"1L`�'`ef Job Ades ^� drs �2City Lot Size (a a��PM T tiY G r 310 - Sad {.J ta�91�(}aL 6. _ Phone �' r Owners Name Address - w - I Contracta �� yy c_q� ddress a <1a License No, a J Phvri - Q F�� TYPE OF WELL/PUMP: NEW WELL.❑ WELL REPLACEMENT ❑ DESTRUCTION ❑yr` PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER'n rn DISTANCE TO NEAREST: SEPZIC TANK" -" - SEWER LINES � DISPOSAL FLD. �PROP.,LINE FOUNDATION, AGRICULTURE WELL OTHER WELL PITS/SUMPS f y` `N INTENDED USE TYPE'OF WELL` PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ' ^�~ Dia. of Well Casing j © Domestic/Private LJGravel Pack ❑ Tracy Type of Casing Specifications i`l Public ❑ Other F71 11 Delta Depth of Grout Seal / '' Type of Grout —. I 1 Irrigation n Approx. Depth• l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump `-H.P. State Work Done J Well Destruction ❑ Well Diameter Sealing Material (top 501.) Depth Filief Material IBeiow 50'I� TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I 1 DESTRUCTION is}.{No septic system permitted it public sewer is I available within 200_feet.! t/Installation will serve: Residence Commercial_ the Number of living units: �._.'_ Number of droam QS Character of soil to a depth of 3 feet: �� table depth LL➢➢ SEPTIC TANK I Type/Mfg I Capacity�d No. Compartments PKG, TREATMENT PLT. ❑ r ci., / f, r Method of Disposal Distance to nearest: Well 5 Foundation. 4�'� Property Line LEACHING LINE 11- No. & Length of lines ' Total length/size 1 4 FILTER BED ❑ Distance to nearest: Well Of. Foundation I 0 Property Line ' SEEPAGE PITS lr'f Depth C2� Size �3 -N mbar _ SUMPS ❑ Distance to neatest: Well �L� 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, l 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 fallowing: "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." TheappEicant st call for al required inspections. Complete drawing on reverse side. A j Signed X Title: Date: y FOR DEPARTMENT USE ONLY 7 Application Accepted by � Date 4 Area I 6C.'l• or Grout Inspection by Dae o Final Inspection by fie Additional Comments: cx - ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 3-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO ♦ EH 13-24 IREV.I i H 51 - EH 14-2e