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APPLICATION FOR PERMIT _ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CAS fr►1 � Telephone (209) 466 67$1 PERMIT EXPIRES 'I'YEAR FROM DATE ISSUED J (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 Rules and Regulations of the San Joaquin Local Health District, Ylob Address 7 �J 3 J ' r/0 City Lot Size PM 1 ,Q w Owner's Name ��✓ �1'" �� '� Address e��+�� 11 � - Phonef , &/ /?' Contractor self Address License No. Phone TYPE OF WELL/PUMP: kNEW WELL © WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r1 , INTENDED USE TYPE OF,WELL_ PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca - Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other {-1 Delta t Depth of Grout Seal Type of Grout - ' I i Irrigation —..Appr6x. Depth I I Eastern Surface Seal Installed by - r , a. Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth'-:-- Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I RFPAIRlADDITION I I DESTRUCTIONK INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: -Residence CommercialOther Number of living units: Number of bedrooms - Character of soil to a depth of 3 feet : Water table depth SEPTIC TANK © Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 1 � Method of Disposal Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest' Well Foundation 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 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 compensa- tion laws of California." i { The applican ust Il for all req ' d inspections. Complete drawing on reverse side. r Signed / Title: Date: � FOR DEPARTMENT USE ONLY �p Application Accepted by ` r t ` Date d Area I Pit or Grout Inspection by vi Dato Final Inspection by Date Additional Comments: &WnC1/;JA_ ZAt ❑ Silk 466-6781 ❑ Lodi 369-3621 p -❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health.Permit/Se ices 1601 E. Ha3elton Ave., P.O. Box 2049, Stk., CA 96241 FEE AMOUNT Di'JE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH r�..EH 13-24 IREV.I H 51 t4 3 � ter in— q,31 EH 14-28