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DL APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 9 YEAR FROM DATE ISSUED I (Complete in Triplicate) k 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.+� ZS P , � � - City S Lot Size PM Job Address _ �- D WtC $ ter Z� I ` i' + ` o I S A Q f�Q "� Phone 7 , Owner's Name�� Address '1 Q r 5[� �,CL License No. � Phone_9" Contractor W L`--'C. Address _ TYPE OF WELL/,PUMP_: NEWWELL ' 'T.aWELL REPLACEMENT © DESTRUCTION LJ _-. PUMP INSTALLATION ❑ 4 SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. LINE r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �� --- - - -ti w.t --w -Dia.of Well Casing a4 f ❑ Industrial LT--open Bottom ❑ Manteca Dia. of Well Excavation v ,Yl " El Domestic/Private ❑ Gravel Pack C1 Tracy Type of Casing Specifications I1 Public ❑ Other ❑ Delta Depth of Grout Seal l , Type of Grout — _-Approx. Depth l 1 Eastern surface Seal Installed by ! 1 1 1 Irrigation ,� ` C � f� p.:` State Work Done _ Repair Work Done ❑ � Type,•of Pump H: I Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth ` Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 41—P&PAIRIADDITION l 1 DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.I Installation-will serve: Residence A--commercial ^-' Other Number of living units: 4Number of bedrooms 22 .... 1 i Water table depth Character of soil to a depth of 3'feet: i SEPTIC TANK FsZ�ype/MfgFA E2 Capacity a No. Compartments PKG. TREATMENT PLT. ❑ ` "} l Method of Disposal I 3 ►. ''� Distance to nearest: Well LIJs� Foundation LD )Property Line PSI a LEACHING LINE VW. & Length-of,.lines'� Total length/size FILTER BED 12Distance to nearest:,I-Well Foundation Property Line i SEEPAGE PITS r,` IBept Size by Number LI� SUMPS, -A- ' ❑ Distance to nearest: Well�.�_�Foundation-If� Property Line i DItpOSAL PONDS f 0 1 i I hereby certify that I have prepared this application and that the-work..Will,6e_done_irtaccordance_with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District following: "I certify that in the performance of the work for which this permit is issued, I shall not Home owner or licensed agent's signature certifies the employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature Cc es the follow,in ify that in the perfoiinance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws alifor6ia." The applic 'm mu all for all r quiz ins ta cions C m to Rraawing on verse s' 4 f Tit Date: �r tl Sign , ` t ;k�,�.�", ,FOR DEPARTMENT USE ONLY 3 ! Application Accepted by �`J�C„>? .. Date Area 1 1 R Pit or Grout Inspection y Date Final Inspection by Date S7 I Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Sox 2009, Silk., CA 95201 FE@ AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY ))ATE f ERMIT NO 4 3; INFO -. pH 24,;(REV.ti/x 51 H 114-26