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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL ON AVE., STOCKTON, CA Telephone 12091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED {Complete in Triplicate) Application is hereby made to the San Joaqui6 Local Health District for a permit to construct and/or install the work herein described. This application is r 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 L Local Health District.f0/ Job Address �. -. �� !S ae / City Lot Size PM Z-0 9 Owner's Name l f Address . Phone 12 1 C44 L L Address Z License No.—Phone_ " Contractor , TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION x PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER .0 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 ❑ Industrial LlOpen Bottom 13Manteca Dia. of Well Excavation Dia- of Well Casing 4 A —,E] Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications (`l Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout _ I I irrigation _Approx. Depth i I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. _State Work Donee - t! - � Well Destruction Well Diameter 2-0 i Sealing Material (top 50') Depth N Filler Material (Below 50') _TYPF<01` SEPTIC WORK: NEW INSTALLATION [I REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted if public sewer's t �+' x available within 200 teet.l ,. Installation will serve: "Residence_ Commercial— Other " Number of living units: ` �',. Number of bedrooms , Character of soil to a depth of 3 feet:- Water table depth SEPTIC TANK ❑ Type/M_ fg' 7 Capacity No. Compartments PKG. TREATMENT PLT. ❑ y { Method of Disposal Distance to nearest:; Well Foundation Property Line i 7L'EACHING LINE ❑ No. & Length of lines Total length/size _ -FILTER BED ❑ Distance to nearest: Well " ' Foundation Property Line s SEEPAGE PITS i I Depth Size _'Number f SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 Di�trjct. 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." r k The applicant must call for all re inspectio Complete drawing on reverse side. t Signed X Title: ! Date: Z FOR DEPARTMENT USE ONLY Application Accepted by Date`S2 -20 +R� Are, k " Pit or Grout Inspection by Data Final Inspection by Date Additional Comments: C_ ` ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 923-7104 ❑ Tracy 835-6385 1€' Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2809, 5ik., CA 95201 �filSC FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"NO. INFO CASH r EH 13.24 IREV.I/A 51 n EH 14-2$ r�