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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ` { 1601 E. HAZELTON AVE.,,STOCKTON, CA i Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM 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 Rules:and Regulations of the San Joaquin Local Health District: f Job Address � � x City Lot Size �+ PM' , Owner's Name ddress n �'7 DX t Z _ _ Phone Contractor Address +� 77¢ /µ ` License IVa. Phone TYPE OF WELL/PUMP: NEW WELL ❑I,,, WELL REPLACEMEN DESTRUCTION ❑ II PUMP INSTALLATIO r �� SYST M RE jkIR ❑ OTFtER ❑ / _ ,.. _ DISTANCE TO NEAREST: SEPTIC TANK SEINER LINES DISPOSAL FLD.&.. PROP. LINE FOUNDATION _ - AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA\ 'CONSTRUCTION SPECIFICATIONS , 1a ❑ In ustrial pen Bottom ❑ Manteca ,3< Dia``of!Well Excavation Dia. of Well Casing t Ll In ❑ Gravel Pack ❑ Trac T , Tracy ype" 'Casing Specifications LJ Public ❑ Other ❑ Delta Depth h of Grout SealType of Grout _l If .� ❑ Irrigation �Approx,.Depth ❑ Eastern Surface-SeaLlnstalledYb ••— •-�- r j I Repair Work Dane ❑ Type of Pum H.P. i YP p �eL� State Work,Done__ +, L DQ Well Destruction Well Diameter Sealing Material (top 50') k !- Depth-2.0,07Filler Material (Below 50'),i 1 a All ` TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION❑ (No septic system permitted if public sewer is + - a available within 200 feet.► Installation will serve: Residence Commerc..I_ Other s (# ! Number of living units: Number of bedrooms�i V) Character of soil to a depth of 3 feet'" � t _ e :�+ i _ _Water table depth SEPTIC TANK ❑ Type/Mfg----y—� Capacity :_ No. Compartments rr $ ► r PKG. TREATMENT PLT. ❑ Method of Disposal t Distance to nearest: Well Foundation Property Line � I LEACHING LINE ❑ No. & Length of lines Total length/size i r FILTER BED ❑ Distance to nearest: Well Foundation Property Line yE 3 1 1! SEEPAGE PITS ❑ Depth r Size t Number SUMPS ❑ Distance to nearest.! Well Foundation Property Liner—.:. � I 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 ordinances, state laws, and rules and regulations of the San Joaquin Local Health District Lj - 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 f 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 applicant t call for ! :a �q d inspections..Complete 1 drawing on' Signed re rse side Titler `YI Date: VTFOR DEPARTMENT USE ONLY M Application Accepted by Date � µ U `" Area D Q Ph or Grout Inspection by Date �� Final Inspection b t a � i P Y Date Additional Comments: 071, ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ T y 835 6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Ha elton Ave., P.O. Box 20M, Stk.. CA 95201 FEE INFO AMOUNT DUE : AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NfO1. + EH 114-26 7-14 I,e51 , ��1b EH 34-26 T7—