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i APPLICATION FOR PERMIT s 4" SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 12091 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (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 welUpump and the Rules and Regulations of the San Joaquin Local Health District. j�qf Job Address "f t �a Ve City PM Lot Size .„,,,,,.,`.Owner.'s Name_] lh A 4 Q.-t/`6 Address Phone SN Contractor ctg1,'o Address t License No. Phone TYPE-OF,.W.ELLI.PUMP-: ._NEW,WELL,L7 _.� WELL REPLACEMENT_ODESTRUCTION C] f PUMP INSTALLATION ❑ SYSTEM REPAIR L1 OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL 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 � FI"Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ' Specifications ' I- Public + n Other Cl Delta Depth of Grout Seal Type of Grout I i Irrigation��- •- •—=.:Approxi..Depth-4 Eastern .--Surface-Seal•Installed by - Repair Work Done ❑ -Type of Pump H,P. State.-Work-Done— Well tate.Work-Done— Well Destruction f ❑r Well Diameter Sealing Material Itop 501 1 Depth Filler Material iBelow 501 TYPE OF SEPTIC WORK:—NEW-INSTALLATION PPIREPAIR/ADDITION I-I-..DESTRUCTION I 1 INo•septic system permitted if public sewer is 1 I' available within 200 feet.) Installation=will-serr6. -Residence Commercial -Other - Number of living units: Number of bedrooms Character of soil to a depthh f 3 feet: y 1 onJ —Water table depth SEPTIC TANK TypelMfg h d- - Gg-,ar.&)Le— Capacity...__ No. Compartments PKG. TREATMENT PLSM_e_thod of Disposal ., ( Distance to nearest: Well Foundation .-._._..._ Property Line ,_,__. i LEACHING LINE No. & Length of lines Ir Total length/size 30 ! FILTER BED PI" Distance to nearest: Well Foundation .. _._ Property Line _._.— t t _ SEEPAGE PITS=�*�., l I Depth Size Number SUMPS " Cl Distance to nearest: Well Foundation 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 compansa- tion laws of California." The applicant must call for.all required inspections. Complete drawing on reverse side. E. Signed X Title: Date: OR PARTMENT USE ONLY �r Date Area Application Accepted by Pit or Grout Inspection by Date Final Inspection by Additional Comments: ❑1Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 - Applicant�Return allcopies 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 PERMI7,NO. INFO CASH + EH 13.24(REV.1 i n 5) EH 14-28 fo