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u.. APPLICATION FOR PERMIT ` SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA li 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. Job Address City Lot Size L/___ pM I Owner's Name r i Address _✓ — —--—��--✓ --/Y/ Phone I �N I _ License No. _ WZ–. j/ _ _�_ Phone Z--'J-;/-;/2 Contractor's Name _ z!YI y 'rr�x�ir Z TYPE OF WELL/PUMP: NEW WELL C1 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 0 Delta Depth of Grout Seal Type of Grout ❑ Irrigation Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Seating Material (top 501 Q0 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residerice Z— Commercial— Other Number of living units'. 1 h Number of bedrooms, Character of soil to a depth of 3 feet: _ __Water table depth SEPTIC TANK Vii] Type/Mfg �i"c Cis r p . No. Compartments ✓ _ � f 'ice c Capacity �2�Pr' �.;r, PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation 17, Property Lina 0 LEACHING LINE Z1 No' & Length of lines – `s f'' Total length/size 3,1( FILTER BED .❑ Distance to nearest: Well Soo' Foundation Property Line SEEPAGE PITS IN Depth Size 36 Number SUMPS ❑ 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 rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "1 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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must tali for all required inspections. Complete drawing on reverse side. Signed ! Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date ! $ Area C? 1 Pit.or Grout Inspection by r Date–'i� Final Inspection by�_�xw.aw., Date 2 -A. aJ sl Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 836-M --- Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 . k FEE AMOUNT'DUE AMOUNT REMITTED CK RECEIVED BY INFO CASH DATE PERMIT'NO. + EH 13.24{REV.16!83) f EH 14-26