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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (249) 466-6781 PERMIT EXPIRES 1' YEAR FROM DATE ISSUED lCornplete 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 welt/pump and the Rules and Regulations of the San Joaquin Local Health District. :..,A !FY6. I 1-1,a 1W_ ora JUL) nuuroaa - Owner's Name -- ---. --- --- ` Phone f ,,//��Addressss / 7 ��f_ ^� / �c� / (�C.+tiS�! License No. or� Phone t0[-510 Contract Addressr0. riJOx�CO TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR D 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 ❑ Open Bottom D Manteca Dia. of.Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack _.r-Gl,Iracy.,.-,. _Type..of.Casing -- Specifications M Public C1 Other CI Delta Depth of Grout Seal Type of Grout — I Irrigation —Approx. Depth t I Eastern Surface Seal Installed by _ Repair Work Done O Type of Pump H.P- Stltte Work Done _ Well Destruction ❑ Welt Diameter Seating Material (top 501 Depth er Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR ADDITION 01 DESTRUCTION I I (No septic system permitted if public sewer is - available within 200 feat.) Installation will serve: Residence Commercial __�__ their Number of living units: _ I _ Number of drooms Character of soil to a depth of 3 feet: — Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. D Method of Disposal Distance to nearest: Well _ Foundation Property Line LEACHING LINE i}"No. & Length of lines T �� ''Total length/size U Xa FILTER BED ❑ Distance to nearest: ' Well +SQ Foundation 16 Property Line_ SEEPAGE PITS I 1 Depth Size '- " r^"-- ' Nurribet SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 I hereby certify that I have prepared this application and that the wdFk will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. 4 Home owner or licensed agent's signature certifies the following: ';I!Eertify 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 hirings 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- tion laws of California." The applicant t call for of qui d inspections. Complete drawing on reverse si Signed Title: r - �/ F Date: 1" f FOR DEPARTMENT USE ONLY Application Accepted by Dete�f/ —� A.//// Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: 0 Stk 466-6781 ❑ Lodi 369-3621- O Manteca On -7104 C] Tracy 835.6385 T Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O, Box 2009, Stk., CA 95201 . EH 13.24 IREV. v n 6 EN 14.26 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY PERMIT -NO. (DATE V