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u APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA 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 9 lw Job Address / O_� �J City / ,. Lot Size PM Owner's Name v'�'- ddress ✓'�/ /V -- Phone Contractor ,"''1 Address License No. Phone TYPE OF WELL/PUMP: NEW 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 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 n Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth ( I Eastern Surface Seal Installed by Repair Work Done 17 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth FillADer Material (Below 50'1 i TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ DITION DESTRUCTION I No septic system permitted if public sewer is 1 ,/C/mmerciather available within 200 feet.) Installation will serve: ResiQence— ol O Number of living units: Number of bedroomst O / Character of soil to a depth of 3 feet: _��(CL Water table depth SEPTIC TANK ❑ Type/Mfg ZB'� Capacity �'y No. Compartments PKG. TREATMENT PLT. ❑ / Method of Disriposal tp�1 Distance to nearest: Well F6undation Ap Property Line t a LEACHING LINE ❑ No. 8 Length of lines jotal length/size FILTER BED ❑ Distance to nearest: Well Foundation__A _ Property Line L SEEPAGE PITS I I Depth �Z Size 2 11 Number UMP L1 Distance to nearest: Well L� Foundation 2&_r X/11roperty Line DISPOSAL PONDS ❑ 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 Dii1trict. 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." call for all requ'ed i spections. Complete drawing on reverse side. The applic 711"mus Signed X Title: Date:tv /y *FOR DEPARTMENT USE ONLY 1 Application Accepted by Da /fJ,� -Area Pit or Grout Inspection by Date Final Inspec on by O , Date. Additional Comments: o ❑ Stk 466-6781 O 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 {- J FEE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO RB INFO ✓6��//)) /\I / /////1 A•nW�-t S EEH 13-24 H 14-144IREV.1ix5i d,(�� , 66