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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA ; , Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED LJ (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 { Lot Size C PM Owner's Name , " ` % n'� Address Phone 1. 711, Contractor~ �� z� v^_/-r` Addres License No• Phone Z-7� TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK f�I/_ - SEWER LINES � � Egg DISPOSAL FLD, ,Y-' (PROP. LINE t f FOUNDATION I 1. � AGRICULTURE WELL OTHER WELL PITS/SUMPS --____- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION_ ( 'Industrial ❑ Open Bottom L1 Manteca Dia. of Well Excavation f a Dia. of Well Casing / ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications k.Public n Other ❑ Delta Depth of Grout Seal 1. Type of Grout 01111A _ Irrigation _�.Approx. Depth i I Eastern Surface Seal Installed by _ Repair Work Done ❑. Type of Pump H.P. - State ark Done Well Destruction Well Diameter Sealing Material flap 5D'1 Depth Filler Material {Below 501 —_ TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i 1 Depth Size Number SUMPS Ll 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 l rules and regulations of the San Joaquin Local Health District. 1 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 must-call for all required,inspections. Complete drawing on reverse side. Signed X Title: a 1 ' .ter r -r- __ Date: FOR DEPARTMENT USE ONLY Application Accepted b Date �) Area Pit out Inspection by ( J q,% /! bate- Final Inspection by Date Additional Comments: t �✓z �+ ° r r �; tiK P ❑ 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 FEE INFO AMOUNT DUE AMOUNT REMITTED �K RECEIVED BY DATE PERMIT'NO. .+ EH 13-24(REV.'si95f 5 [)t �� J fL' - r• � /_ EH 14-26 - tU