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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1`YEARFROM 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 well/pump and the Ryles and Regulations of the San Joaquin Local Health District. Job Address City Lot Size r47W 'S� PM Phone 671 e2 III Owner's Name Address �;V1I� �� e Contractor Address License No. Phone TYPE OF WELL/PUM NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES � X, DISPOSAL FLD. PROP. LINE ` FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS V ' INTENDED USE TYPE OF WELL PROBLEM AREA, CONSTRUCTION SPECIFICATIONS _ _ 1 El Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack__. —D Tracy'—_ Type of Casing Specifications ❑ Public,' -❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigationpprox. Depth C1 Eastern --Surface SealFled by Repair'Work Done Q1 Type of Pump H.P. State Work Done Well Destruction "❑ Well Diameter Sealing Material (top-50')I J ' DepthFiller Material (B 1ow 501 TYPE OF SEPTIC WORK; NEW INSTALLATION ❑ REPAIR/ADDITION ❑—DESTRUCION o septic system permitted if public sewer is available within 206-feet.) Installation will sera Re idence—Commercial_ Other ` Number of bedrooms Number of living units; Character of soil.to a deptfi of 3 feet: Water table depth SEPTIC TANK SP1 ❑. ,Type/Mfg;:r-j'"" " Capacity No. Compartments i. PKG. TREATMENT PLT..❑ 4 Method of Disposal Distance to nearest: Well ,Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line . SEEPAGE PITS '❑ '"Depth I Size Number SUMPS ❑ Distance tonearest: Wel Foundation .Property Line DISPOSAL PONDS ❑ 4 $ T k 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 I 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: "1 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tio ws if California." e a lc t must call or all required inspections. Complete drawing on reverse side. Sig Title: Date: ^LQ � FOR DEPARTMENT USE ONLY Application Accepted by, Date 5 A e C) t Pit or Grout Inspection by Date Final Ins ction by lJ Additional Comments: ❑ Stk 466781 ❑ Lodi 369-3621 ❑ 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 95201 FEE AMOUNT DUE AMOUNT REMITTED CK# RECEIVED BY DATE PERMIT'; INFO + H 13-24 EH14-26IREV.t/B57 �� .l© ` �� ,. (b C 85-77