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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED - s 3 / U (Complete in Triplicate) Application IUs hereby made to the San Joa uin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin Co my Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health/DDs t.e,, / // U j /4b�• � i Job Address City Lot Size ID L Owner's NamesQ Address Phone I Contractor Address License No. rl 3.1 Phone I I TYPE OF WELL/PUMP: PXW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP'INSTALLATION ❑ SYSTEM-REPAIR- ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DfSPOSAL FLO. -PROP,-LINE FOUNDATION_ AGRICULTURE WELL_—_ OTHER WELL _.PITS/SUMPS _ INTENDED USE TYPE'OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i ❑ Industrial ❑ Open Bottom ❑.Manteca Dia- of Well Excavation Dia. of Well Casing 1 ❑ Domestic/Private ❑ Gravel-Pack= -� ❑•Tracy - , Type of Casing 1 _ Specifications 1-1 Public 171Other {1 Delta Depth of Grout Seal `' .. c _7ype of Grout I I Irrigation _--Approx. Depth l I Eastern Surface Seal-Installed by Repair Work Done ❑ Type of Pump H,P. state Work pone Weil Destruction ❑ Well Diameter Seafing Material {top 5('] Depth Filler Material (Below 50') , TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION I I {No septic system permitted if public sewer is �� —^-�available-tivithin 200 feet.) Installation will serve: Residence— Commercial Other ' Number of living units: . Number of bedroom / Character of soil to a depth of 3 feet: _ I Water table depth z SEPTIC TANK ❑ Type/Mfg s Capacity No. Compartments PKG. TREATMENT PLT. ❑ Mf I Method of Disposal Distance to nearest: r Well Foundation Property Line i LEACHING LINE 1Z No- & Length of lines Z,9-V Total length/size FILTER BED ElDistance to nearest: Well / /1 Foundation -_ Property Line /0 3 SPITS I 1 Depth �//J Size_ _ Humber 112 Distance to nearest: Well /_15712 Foundation Foundation/0 -A Property Line , DISPOSAL PONDS ❑ f 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 no employ any person m -manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the folio ng:"I certify tha in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of lif a.' The applic ust lI r II re re inspec s. Complete drawing verse side. s _ Signed X Tit � Date: FOR DEPARTMENT USE ONLY i Application Accepted by Date ) Area Pit or Grout Inspection by Date Final Inspection by Dat ' Additional Comments: ❑ Stk 466-6781 ❑ 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 INFO AMOUNT DUE AMOUNT REMITTED CA RECEIVED BY DATE PERMIT NO. r !� �J I + EH 13-24(REV.1/8 5) rJ ✓',p o(�Y 7 (fir n EH 14-26 7 r rl� l•fI y