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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.', STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ;. 1 (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. { Job Address t 347-1 // t City .[.0 Lot Size PM Owner's;ame • Address Phone -Contract f Y ,�...Address ` 'r --A0-2 (a - License No: ..�PhoRe TYPE OF WELL/PUMP: \NEW WELL ❑ WELL REPLACEMENT ❑s'. DESTRUCTION ❑. - tr PUMP INSTALLATION ❑ SYS TEMIREPA R_�Ll�`;� >i•pTHER;O.�` DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE r ^"•� FOUNDATION >^ �^— AGRICIfLTURE-WELL" °�•-^-T-OTHER-WELL —n'PITS/SUMPS—--" r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ' El Open Bottom ❑ Manteca Dia. of Well Excavation pia!of Well Casing El Domestic/-Private -„, ❑ Gravel_Pack ❑ Tracy T e of Casin YP 9 Specifications ❑ Public41� 1:1Other t ❑ Delta Depth of Grout Seal " Ll Irrigation _A T-yFj_,of_Grout_ pprox.{Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ F'Type of Pump H.P. State rllVork Done �- Well Destruction ❑ Well Diameters Sealing Material /top 50') x. 0 Depth Filler Material (Below 50') ff f TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.l Installation will serve: Residence Commercial— Other Number of living units: Numbei o bedro ms Character of soil to a depth of 3 feet: Water table depth 1 0 SEPTIC TANK 15" Type/Mfg I Capacity No. Compartments PKG. TREATMENT PLT. C1 �-y'INo. Compartments of Disposal Distance to.nearest:,r .._Well_ J�` Foundation .— Property Line-S — ' f _ � LEACHING LINE ❑ No,'& Length of lines - --- Total length/size FILTER BED ❑ Distance to nearest: Weil Foundation `4'-' .,�.,,...�•,�. Property Line { a, _ y, ,. SEEPAGE PITS !I Depth Site- r�' '`� rNumbere.5a�tv a'.� I SUMPS ❑ Distance to nearest: Well Foundations_ Property Line�. s DISPOSAL PONDS 10 .. '.� ' ',�.,,- t..�f r i hereby certify that I have p patediha`application and that the work will-be done in accordance with San Joaquin-coun rules and regulations of the San Joaquin Local Health District. ,, q ty ordinances-state laws, and Ing: Home owner or licensed agent's signature certifies the followri em to g: '"I certify that in the perfo*mance of the work for which this permit is issued, I shall not p y any person in such-manner as�to become-subject'to workman's compensation laws of California."Contractor's hiring or sub-contracting,signature tion certifies the laws of California.1 ..i certify'that;i6 the'pertorman'ce-of.tFie woik,for which This permit is issued, I shall employ persons subject to workman' applicant must call fo<r5all r guired inspections. Complete tlrawing on reverse sil Y' Signed :KA"�-V C- Title: r f l r � Date, �7 R'BEPARTMENT USE ONLY Application Accepted by Area I �� r `Pit or Grout Inspection by Date Final Inspection by / Date Additional'Comments: ❑ Stk 466-6781 ❑ Lodi 369-36'11 ❑ Manteca 823-7104 ❑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 INFO CASH RECEIVED BY DATE PERMITNO. + EH 13-24(REV.I/a5) ��+ fl g EH 1426 - �� O S ,