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;.APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (2091 466-6781 �G 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. ,� Q Job Address � t 7 f/21. - City at Size M Owner's Name I/ ! ] �T r(� r' Address 's Phone Contractor! � �� /J'l/J ,�_Address G' License No. e yS Ph / '1'`TYPE OF WELL/PUMP: NEW WELL d WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION'C]' SYSTEM REPAIR .fly t OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK LINES DISPOSAL FLD. PROP. LINE` FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF."WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' , Ll Industrial ❑ Open BdttOM"4 ❑ Manteca Dia. of Well Excavation r + Dia. of Well Casing ❑ Domestic)Private ❑ Gravel Pack ❑ Tracy Type of Casing t. r Specifications; I ('1 Public fl'Other .❑ Delta Depth of Grout Seal-' Type of Grout _ 'f �1 1 Irrigation _-Approx. Depth I i 'Eastern r+ Surface-'Seal Installed by _ t ' Repair Work Done ❑ Type of Pump-1. ' H.P. State Work Hone _ Well Destruction ❑ Well Diameter ySealing Material (top 501 r s Depth Filler Mateiial (Below 501 Ilk TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITIONAr DESTRUCTION I.1 (No septic system permitted if public sewer is available within 200 feet-) �y Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms.y - � ! Character of soil to a depth of 3 feet: Water table depth = SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments '2-- PKG. TREATMENT PLT. ❑ t Method of Disposal r Distance' o nearest: Well 4(� Foundation . J-40- Property Line / y" f LEACHING LINE D No. & Length of lines 3- 90 1 Total length/size FILTER BED Eldistance to nearest• Well Foundation Property Line f f ' SEEPAGE PITS I I Depth Sire Number l SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared-this pplication and that the work will be done in accordance with San Joaquin county ordinances,'state laws, and 1 rules and regulations of the San Joaquin Local Health Di§trict.,. j 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 subcontracting 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- I tion laws of California." The applicant m II far all r quVdi ctions. Complete drawing on reverse side. L ^� / Signed X Title: _ Date: / FOR DEPARTMENT USE ONLY Application Accepted by Date 7/a 6 Area Z t �} Pit or Grout Inspection by Date Final Inspection by Date I Additional Comments: _ ❑ Stk .466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 D Tracy 835-6385 Applicant - Return all copies to: Environrhental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 f FEEAMOUNT DUE' AMOUNT REMITTED C K H RECEIVED BY PERMIT NO. INFO EH 13-24 I + REV.1/K51 � } � 00 6 EH 11-28 .?� ! !