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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 ' (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 i 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 /[°. City Lot Size PM { t 1 ""Owner Nam Addressr 5_S Phone /Lz/ LC�4 w �r Contract Address-_� � & License No. Phone TYPE OF.WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ + PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Wel! Casing 4 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications } I'1 Public n Other 1_1 Delta Depth of Grout Seal Type of Grout I I Irrigation --Approx. Depth I 1 Eastern Surface Seal Installed by i Repair Work Done ❑ Type of Pump H.P, State Work Done — l. Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth ler Material /Below 50') I — TYPE OF SEPTIC WORK: NEW INSTALyATION I ] PAI ADDITION DESTRUCTION l I INo septic system permitted if public sewer is available within 200 feet.) -Installation.will•serve: Re idence=�-Cornmercial% �''1 Other`- t Number,of living units: Number edroo Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ,, Type/Mfg *Capacity No. Compartments PKG. TREATMENT PLT. O f r Method of Disposal Distance to nearest: Well � Foundation t-5 Property.Line LEACHING LINE �v ❑ No. & Length of lines Total length/size nn 4 .FILTER BED ❑ Distance to nearest: Well Foundation Property Line r�- i _ f 5£EPAGE PITS 11 Depth Size Number SUMPS } X Distance t nearest: Well DISPOSAL-PONDS ❑ . r _ 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 rogulations of the-San'Joaquin Local Health District. Home owner or licensed agent"-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 this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." The applicant t call for all eq iced spections. Complete drawing on reversV'ef)t Signed X Title: ._ Date o 9,9 CT FOR DEPARTMENT USE ONLY Application Accepted by Date Area Q r out Inspection by ate incl Inspection bydit n,I Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 p Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 F AMOUNT DUE AMOUNT REMITTED K H RECEIVED DATE PERMIT'NO. +-EH i3-241REV.""ti, ✓' �-7 I� EH 14-2e N--ld- / c.-