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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.,SSTOCKTON, CA Telephone (209) 466 -6781 r PERMIT EXPIRES 1 YEAR FROM DATE ISSUED .i (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. Job Address [ City ik—Lot Sizeea M ih Owner's Na Address Z AJ Phone 7J I t Contractor Address No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ,• OMP, INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Q 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 Is ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 4�d ---------- 0 Domestic/ 0 Gravel Pack ❑ Tracy Type of,.Casing Specifications ❑ Public ElOther ❑ Delta Depth gout Seal Type of Grout '1141 ❑ Irrigation Approx. Depth,, ❑ Eastern- Surface Seal Installed by R air Work.Done ❑ Type of Pump H.0, .. t State Work Done W II Destruction D Well Diameter Sealing MateivaYltop 501 I Depth Filler Material l6elow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ 'REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial Other 3 k I f Number of living units: Number of bedrooms Character�of soil to a�depth of 3 feet: Water table depth � SEPTIC TAfJK/ ❑ Type/Mfg f"� Capacity No. Compartments � _ PKG. TREATMENT PLT. ❑ � - i Method of Disposal j ✓/ DistancaAo-nearest: Well t Fou dation Property Line A. LEACHING LINE P-INO. & Length of lines 7Total-length/size — 4 FILTER BEb'' 'X ❑ Distance-to-nearest: Welllll Foundation1 ;j � r Property Line € ' SEEPAGE PITS_' 1� -C DApth S.ize 5-3 ``� Number SUMPS El Distance to'nearest: Well : Foundation Property Line—�f DISPOSAL PONDS I Eli - 1 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. .. .f Homeowner or licensed agent's{signature certifies the following s''Ihcerttify tha1t 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 wor.Cmari's compehsation laws of California." Contractor's hiring or sub contracting signature p _,"� 2 . certifies the following: "I certify that m-the of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion: laws of California.' I Thet appli77 II for all r uifed i pes. Complete drawing,_,on reverse side. Signed X cti Title: r- Date: . FOR DEPARTMENT USE ONLY 'Q �-- Application Accepted by 1 Date y Area Q „� ^'^" Pit or Grout Inspection by Date 5 Final Inspection by Date ✓. I ` . 5 Additional Comments: ElStk 466-6781 C1r 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 4111f FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. f INFO aw r/y f + EH 13-24(REV.I/x5) /� EH 14-28 ' L / } � t