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APPLIC ION.FOR PERMIT SAN JOAQI LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA } Telephone {2091 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED1` , (Complete-in Triplicate) ., „ i 3,f'tw 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 forwell/pump and the Rules and Regulations of the San Jo quin Local Health District. ��yy Job Address oL6 q " r- A -. City Lot Size. PM Owner's Name fJ ' AddressIfy „ �n _ Phone Contractor •Address .� #� License No. Phone TYPE OF WELL/PUMP: NEWWELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ � SYSTEM REPAIR ❑ OTHER El TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP- LINE If FOUNDATION ! AGRICULTURE WELL OTHER WELL PITS/SUMPS t {INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑'Industrial ❑ Open Bottom ' ❑ Manteca Dia. of Well Excavation Ca Dia. of Well sing ❑ Domestic/Private El Gravel Pack 1 ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other " ❑ Delta Depth of Grout Seal Type of Grout ❑Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Materia! (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) J) 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 i SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line 1 _ d LEACHING LINE ❑ r No. & Length of lines Total length/size FILTER BED �" �❑ -Distance to nearest:' Well T Foundation Pro _ - perty Line SEEPAGE PITS D Depth P Size :r.rF •e i , 1 Number 6 SUMPS"`,"a 1;` +3 et �- a• .. I ❑: Distance' 'ty nearest: Well - 21 Foundation- Property dation DISPOSAL PONDS 13 Property Line ' 1 hereby certify that I have prepared this application and that the work will be'done in accdrdance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. �Nk Home owner or licensed agent's signature certifies the following: "I cert( that in the employ an certify performance,of the work for which this permit is issued, I shall not P Y y 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 ust call for all required " sPections. Complete drawing on r arse side. �r' Signed t �. iz/ r 4 / Y-2 -- �� Title: Date: FO EPARTMENT USE ONLY kr Application Accepted by Date Area Pit or Grout Inspection byD ate Final Inspection by Date Additional ❑ Stk 466-6781 Lodi 369-3621 ❑ Manteca 823 7104 ❑ Tracy 8W6395 Applicant- Return all copies to: Environmental:Health Permit/Services.1601 E. Hazelton Ave., P.O. Box 2009, Stk.; CA 95241 FEE AMOUNT DUE AMOUNT REMITTED CK INFO RECEIVED BY DATE PERMIT'NO. + EH 13-24 IREV.v x 51 0Q EH 10-28 W4