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Y APPLICATION FOR PERMIT } SAN JOAQUIN LOCAL-HEALTH DISTRICT � 9 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone 12091 466-6781 PERMIT EXPIRES 1-YEAR-FROM DATE ISSUED 4 " f. ,�o;r• :3 (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 i Local Health District Jab Address Y Ctty Lot Size PM *- essv � Phone Owner's Name _ u g� r' Phone ��v 7 Contractor's Name nse Na. TYPE OF WELLIPUM i FW WELL El WELL REPLACEMENT EJ DESTRUCTION 13 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ ilor i OTHER D 4 ; DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. 1;PROP. LINE li FOUNDATION AGRICULTURE WELL - OTHER WELL $-PITS/SUMPS,— INTENDED USE TYPE OF WELL PROBLEM AREA. CONSTRUCTION SPECIFICATIONS ' E) Industrial C1 Open Bottom ❑ Manteca_ ` Dia. of Well Excavation- Dia. of Well Casing ❑. Domestic/Private F-1 Gravel Pack ❑ Tracy Type of Casing _ Specifications ❑ Public ❑ Other ElDelta *'-� Depth of Grout Seal + Type of Grout— * Irrigation rout❑ Irrigation °f•'��"�---Approx. Depthb' [I Eastern Surface Seal Installed by J Repair Work Done ❑ Type of Pump ,f H.P: State Work Done Well Destruction ❑ Well Diameter • """ Sealing_Material (top 501 Depth Filler Material (Below,,) { TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is i available within 200 feet.) Installation will serve: Residence Commercial Other > Number of living units: Number'of bedr msI Character of soil to a depth of 3 feet: 11 Water table depth SEPTIC TANK ❑ Type/Mfg J 4 Capacity - No. Compartments PKG. TREATMENT PLT. ❑ t. 4 iy. Method of Disposal Distance to'nearest: Well Foundation Property Line LEACHING LINE No. & Length of lines - f Total Length Size I Foundation . Pr party tine FILTER BED ❑ Distance to nearest: Well jitr) SEEPAGE PITS -Depth Size m er SUMPS ❑ Distance to nearest: Well Foundation Prope Liljg 4 DISPOSAL PONDS LlV I hereby certify that I have prepared this application and that the work will be do in r an it a?'Woaquin 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 th rmce he�ork for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation I of tali Ia."Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this pe is issued shall employ persons subject to workman's compensa i tion laws of California." The applicant usti f II requi d inspections. Co tete drawing on regerse side. f •»-,* (jyj�J �� — Date: Signed "Title: - FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by y Date Additional Comments: ; ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 Applicant- Return all copies to: Environmental Health Perrnit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO.' INFO +EH 13-24(REV.10163) S. Oa vg�-- EH 14-28