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\ 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 of No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 7a Job Address LJ C Lot Size 7� . PM Owner's NamAddress If, � ' � ��r� /!/. QPllone �23 -153 Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACE NT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM EFAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER INES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICUL URE LL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREANSTRUCTION SPECIFICATIONS El Industrial ❑ Open Bottom ❑ Manteca D . of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ TracyTyp of Casing Specifications ("1 Public ❑ Other F1Delta Deptof Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Easter Surtac Seel Installed by _ Repair Work Done Ll Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top ) Depth Filler Material (Below _ TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) ()J Installation will serve: Residence Commercial_ Other Number of living units: __L__ Number of bedrooms 4 , V Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg Capacity l 600 No. Compartments PKG. TREATMENT PLT.❑ T Method of DispoS Distance to nearest: WeII { 'V'0 Foundation Property Line 1 V T LEACHING LINE No. 8 Length of lines Lotal length/size FILTER BED ❑ Distance to nearest: Weil. I U011 Foundation ��` Property Line SEEPAGE PITS +t Depth as Size y !7 // INumber SUMPS LI Distance to nearest: Well Foundation Property 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 District. 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." The applicant st call f all req 1ilspections. Complete drawing on reverse side. Signed Title: ��+--+�+��' Date: ap n.• F PARTMENT USE ONLY Application Accepted by �'LY CMA •`^ ' k&&CAd AV , Date -1.,—C)Q Area 9 Pit or Grout Inspection bye' ,/a ; Date Final Inspection by Date o-/0- Additional Comments: 'h 7 V S l ❑ Stk 466-6781 ❑ 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 FEEINFO OUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. • EEH H 13-24 IRMv x s� •0�