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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T OIV AVE., STOCKTON, CA Telephone (209)-466-6781 PERMIT EXPIRES 1 YEAR'FROM DATE ISSUED'' : M (Complete in Tripllcate), t 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 Ryles and Regulations of the San Joaquin Local Health District. Job Address V"-7 70 1 # l — �" : ` Cit1'I Lot Size PM" cLC - : Phone Owner's Name AAddress r Address /L.O�-. � �/ ' T�p License [Vo. _....Phone g6�� .t Contractor_,. TYPE OF WELL/PUMP: NEW WELL A❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ + A PUMP INSTALLATION ❑ ,4 SYSTEM REPAIR-El " OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE J FOUNDATION AGRICULTURE WELL OTHER WELLY PITS/SUMPS INTENDED USE TYPE OF.WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �". Ll Industrial ❑""Open Bottom ❑ Manteca- Dia. of Well Excavation Dia. of Weil.Casing 0-Domestic/Private 1 x ❑ Gravel.Pack ❑ Tracy Type of Casing Specifications 11-Public '❑`Other' ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation -L—Approx. Depth ❑ Eastern Surface Seal Installed by [ - Repair Work Done ❑ Type of Pump H.P. State Work Done t M Well Destruction ❑ Well Diameter Sealing Material {top 50'1 Depth ` ' Filler Material {Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION, REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is -. i available within 200 feet.) I Installation will serve: Residence 4� Commercial Other_ m M N tuber of living units: Number of bedrooms 3 w �- Character of soil to a depth of 3 feet: 0 i-d � Water table depth SEPTIC TANK ❑ Type-/Mfg Capacity �.r '-'. No. Compartments f PKG. TREATMENT PLT. ❑ _ ' Method of Disposal � I — �' Distance to nearest: �Welf, FoundationF1/,• t �'.-Propertq,Line LEACHING LINE O No. &Length of lines=\t Total length/size FILTER BED i❑ Distance to nearest: Well 99 �FoundationProperty tine SEEPAGE PITS El Depth j�� Size- '�X�a Number SUMPS 1 Distance to nearest:. Well ZO&A77—Foundation Jr= Property Line��. � DISPOSAL PONDS _ } 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 regulations'of the San Joaquin Local Health District. {, Home owner or licensed agent's 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 must call for II re din coons. Complete drawing on reverse side. .„ Signed X �.� 1 t y Title: Date: F ;R DEPARTMENT USE ONLY Application Accepted by / / Date Area �� Pit or Grout Inspection by= Date � � Final Inspection by 5 Date Additional Comments: . ❑ Stk 466-6781 ❑ Lodi 369-3621. Mante -7104 ❑ Tracy 835-6365' Applicant-Return all coples to: Environmental Health Permit/Services 1601 E. Hazelton Ave.'P.O. Box 2009, Stk., CA 95201 c " ! FEE s AMOUNT DUE AMOUNT REMITTED ""CASH;�' RECEIVED-BY.. ,,,,,.,,.,DATE _ , PERMIT"NO... ... _._ I 11 FO !/!1/L./✓n'!�,.V�Jl.�� a ..R... _,.. ar- -. n- =�..w� 7 [ ' 57S- r EH 174.REV.1e57 EH 14-26