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APPLICATION FOR PERMIT SAN JOAO.UIN LOCAL HEALTH DISTRICT 1601 E. HAZEILTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) i 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 Local Health District. Job Address � alul'/e r City � ! J Lot Size V-11Q PPM�� a Owner's Name Not 1C A✓'ny Address 7 u/• " Phone FR3 Contractor's Name, License No: Phone (� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ (. ' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ r i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i FOUNDATION AGRICULTURE WEAL u OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public C1 Other ❑ Delta Depth of Grout Seal a 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 501 Depth - .Filler Material"(Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION)( REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_)C Commercial— Other Number of living units: Number of bedrooms 2— - Character of soil to a depth of 3 feet: 14A0012a13WI `r Water table depth SEPTIC TANK EJ--Type/Mfg Z1+1E L- —Capacity l aca No. Compartments PKG. TREATMENT PLT. ❑ fsSCR nk Method of Disposal Distance to nearest: Well 6t Foundation l p r Property Line cis r LEACHING LINENo. &Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 4L- Depth Size 33 Number a SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 4 1 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 regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "l 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 com.perlsation 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 applicant m t call ►all required " s ctio . Complete drawing on'reverse side. Signed Title:f` C'/II��` Hate: �FOR DEPARTMENT USE ONLY Application Accepted b `L��'Y �'�! � r —_ Date ! Area I QJ� Pit or Grout Inspection by ' Date Final Inspection by f Date r 1 W Cv Additional Comments: III IF VN10144_� v► N 1`r ` ' y 8-6k 466-6781 Lodi 3621 EI Manteca 823-A04 Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH JJ r� + EH 13-24(REV.10/83) '--f EH 14-28 !v