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APPLICATION FOR PERMIT o D . SAN JOAQUIN LOCAL HEALTH DISTRICT t 1601�,E. HAZELTON.AVE., STOCKTON, CA �< f Telephone`-{2pg'I,466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) r Application is hereby made to the San Joaquin%Local Health District for 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 Crty FSize PM Owner's a ff Address �Iy Phone Contractor Address X�f 1 Licens/No. `-'� hone L 6 TYPE OF WELL/PUMP: N WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ IN % li .30. ?V t, ) PUMP INSTALLATION ❑. f SYSTEM REPAIR'p,. OTHER ❑ DISTANCE TO NEAREST: SEPTICITANK SEWER LINES DISPOSAL_FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER:WELL-'"- -- 'PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS '- A � ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation .' 'Dia. of Well Casing�l V-11 ❑ Domestic/Private ❑ Gravel;Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other i ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑Fastern Surface Seal Installed by Repair Work Done, Type of Pump H.P. l State Work Done CAL-, . Well Destruction © Weil Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION M REPAIR/ADDITION O 'DESTRUCTION ❑ (No septic system permitted if public sewer is r i , r available within 200 feet.) Installation will serve: Residence_ Commercial Other t __ Numberof�living units:: � Number ofbedrooms Character of soil to:.a depth of 3 feet:. "'M-" """ - Water table depth SEPTIC TANK ❑ 'Type/Mfg J Capacity r No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation r Property Line a ' G i LEACHING LINE ❑ No. & Length of lines Total length/size 1 FILTER BED ❑ Distance to nearest: Well Foundation Property Line x ) SEEPAGE PITS Cl Depth Size Number ' SUMPS ❑ Distance to nearest: Well Foundation ' Property Line DISPOSAL PONDS ❑ ( 1 I hereby cert; repared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules an gulations of the an Jpaquin Local Health District. s �� s Home wner or licensed age 's sionatu certifie th following: "I certify that in the performance,of the work forwhichthis permit is issued, I shall not empl y any person in such nnerAs b o su act to workman's compensation laws of California."Contractor's hgnng or sub-contracting signature cert; res the following: "1 1fy t t i rm ce of th permit is issu , I shall employ persons subject to workman's compensa- tion laws of California." I The pp"can II or all s. Cc plete drawing reverse sidAO . Signe Title:!, fDate: FOR DEPARTMENT USE 0NLY Application Accepted by � Date Area f-G77� I Pit or Grout Inspection by Date Final inspection b DateL�2G `� i Additional Comments: w ❑ Stk 4W-6781 ❑ Lodi 369-3621 ❑ 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 r � ! r INFO FEE AMOUNT DUET AMOUNT REMITTED CASH" ~ RECEIVED BY DATE PERMIT NO. + EH 13-24/REV.I/a57 EH 1428