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r APPLICATION FOR PERMIT r' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA. Telephone (209) 466-6781 PERMIT EXPIRES '1 YEAR FROM DATE ISSUED I (Complete in Triplicate) I 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 C unty Ordinance No. 549 for sewage or No. 1862 for welUpump and the Rules and Regulations of the San Joaquin Local Health District. [� 2 . Job Addres (�( City Lot Size PM i I Owner's Name Address � Phone f` Contractor s _ _Address License No. / Phones 664 !w? TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cl 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 ("1"Public Fi Other ❑ Delta Depth of Grout Seal Type-of Grout ! I Irrigation --Approx. Depth t I Eastern Surface Seal Installed by VRepair Work Done ❑ Type of Pump H.P. State Work Done t Well Destruction ❑ Well Diameter Sealing Material (top•501 Depth Filler Material (Below 5018 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION Or DESTRUCTION I 1 (No septic sydtem permitted if public sewer is available within 200 feet.] ki Installation will serve: Residence( Commercial Other Number of living units: Number of bed r oms_ ll�� r �� Character of soil to a depth of 3 feet: Water table depth ! SEPTIC TANK LYType/Mfg 1t Capacity No. Compartments PKG. TREATMENT PLT. ❑ ; _ t Method-o( Disposal I� Distance to nearest: Well, Foundation d-43 Property Line I LEACHING LINE CC/f4o- & Length of lines � r' Total length/size i FILTER BED C] Distance to nearest: Well D f Foundation 30 1 Property Line t ff ay SEEPAGE PITS ILl-- Depth ID S Sizo ��'� _ Number SUMPS Ll Distance to nearest: WellF SSL..___.._._ Foundation Q I _ Property Line' {ti (� DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the wgtk will be done n accordance with San Joaquin,county ordinances, state laws,andfr��•i rules and regulations of the San-Joaquin LoF61-WeAth Di§trict. ---- ` Home owner or licensed agent's signature certifies the following "Iycegif<ibk in the performance of the work for which this permit is issued, I shall not e.$ d'rk I employ any person in such manner as to"bee'omublect to wman's compensat)on laws of.California." Contractors hiring or sub-contracting signature i certifies the following: '.'I certify that in the performance'of ills�Nork for which`this permit is issued,I shall employ persons subject to workman's componsa- tion laws of California." ;.s _• _f r The applita pL must call for 4 required inspections:.C6,,mplota drawin;[;an-reverse_side.__-.` i SignedX /f Title:" + I Date: FORDEPARTMENTUSE ONLY Application Accepted.by Date ` ! Area I _ i cit) t r Grout Inspection by ^ z :O�tef L� Final inspection by Dat �� t; Additional Comments: ❑ Stk 466-6781 a ❑ Lodi 369-3621 ❑ Manteca 823.7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Stirvices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED 'CASH 40 RECEIVED BY DATE P£RMIT'NO. ♦.EH13.211REV.1iK51 �� • dv �V�� %_ /S: • ��j�� EH 11-2e