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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601. E. HAZEL TON AVE., STOCKTON, CA �b Telephone 12091 466-6781 PERMIT EXPIRES 1-YEAR 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. rc� Job Address &_4tJ /QCity Lot Size PM Owner's Name 1 le 1 �A +L/ Address Phone r Contractor Address /G v f icense N Phone TYPE OF WELL/PUMP: N W WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR p OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK j ...�_-._ SEWER LINES DISPOSAL FLD. PROP. LINfi[J� FOUNDATION �J2 AGRICULTURE WELL -- OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO S r ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Fxcavab / Dia. of Well Casing ❑ Domestic/Private Gravel Pack ❑ Tracy Type of Casing ® Specifications Public ❑ Other Delta Depth of Grout Seat z519 i+ Type of Grout f- 1 Irrigation App ox, Depth I I Eastern /urf ce Seal Installed by /t'/�I�l')✓/1'1Q�lS _ S Repair Work Done ❑ Type of,Pum �. State Work Done _ s Well Destruction 1=J Well Diameter Sealing Material Itop 501 J Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION l 1 DESTRUCTION I 1 (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 l No. Compartments ' PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that.1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, 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."Contractors hiring or sub-contracting signature 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." The applica t ca al quired inspections. Complete drawing on revers ide. //Signed t tie: 4W ems"y ` Date: FOR DEPARTMENT USE ONLY Application Accepted by _._ Date Area Pit or Grout Inspectin by t ;F Date 6, Final Inspection by Date, Additional Comments. V + ❑ Stk 466-6781 ❑ Lodi 369.3621 Manteca 823 04 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO A+M0U�N+T+ DUE AMOUNT REMITTED CASH CK 9 RECEIVED BY DATE PERMIT'NO. +.EH 1 8-241REV.t/K57