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APPLICATION-FOR PERMIT OQS-! >'-� SAN JOAQUIN LOCAL HEALTH DISTRICT w 16011 E. HAZELTON AVE., STOCKTON, CA �V[ Le �ry Telephone {209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is he4eby 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 _. City Lot Size PM Owner's Name Address Phone Y4329 ti Contractor /) l4 In� __..._ Addfess License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION El- PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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 i ,. ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F1 Public Cl Other r_1 Delta Depth of Grout Seal Type of Grout I I Irrigation _._Approx.•Depth I I Eastern Surface Seal,Installed by OJ�1 Repair Work Done ❑ Type of Pump € H.P. + State Work Done_ Well Destruction ❑ Well Diameter ( Sealing Material (top 50') Depth ) Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1 lj REPAIR/ADDITION ! DESTRUCTION-I I (No septic system permitted if public sewer is [// ° available within 200 feet.l { ` , Y . Installation will serve: Residence_ Commercial_ Other Number of living units: Nurnber of bedrooms t � Character of soil to a depth of 3 feet: -Water table depth n\ SEPTIC TANK ❑ Type/Mfg - Capacity No. Compartments �J PKG. TREATMENT PLT. ❑ r Method of Disposal ! l Distance to nearest;� Well Foundation Property Line r _ LEACHING LINE No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well SO"- Foundation�� Property Line 1 SEEPAGE PITS I Depth Size SV. 7- 4 ` Number SUMPS Cl Distance to nearest: well 1130 Foundation 20 i• Property Line DISPOSAL PONDS ❑ I I hereby certify that I have prepared this application and that the work will be done:in accordance with San Joaquin county ordina ces, state rules and regulations of the San Joaquin Local Heaitli District. l 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'no' 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: '9 certify that in the performancepf-ttie work Pr which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant cat r all eq d inspections. Complete drawing on reverse side. Signed X I Title: Date: &T I f 6 FOR DEPARTME=NT USE ONLY Application ccepted by - Date Area �+ rout Ins coon Date -A.94D ! Final lns-p' `tion`,by Date Additional Comments ❑ Stk 466-6781 ❑ Lodi 369-3621 r ❑ 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 9520FEE ' INFO AMOUNT DUE AMOUNT REMITTED ; C 5!t RECEIVED 43Y DATE PERMIT No. f +.CH 13-244REV.1/a 5) EH 14-29 �(,�