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�? APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON ON 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 or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address l s [J City 1 Lot Size 16Iort�.nt' PM Owner's Name cL AddressI L�l nrye � - 'Al �7/is/�g� �4_.0Phone -- S3 y g• Contractor ON + C Address ,.i' 4W " License No. [ Phone TYPE OF WELL/PUMP: NM WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE d FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial Ll Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing �f ❑ Domestic/Private Gravel Pack ❑ Tracy Type of Casing.-...deJC Specifications .714 4/0 i'1 Public 1-1 Other n Delta Depth of Grout Seal _ Type of Grout I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by— Repair Work Done L3 Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50) r TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION I 1 INo 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. Cl 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 r SEEPAGE PITS i I Depth Size —Number SUMPS ❑ Distance to nearest: Well Foundation Property Line S 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 taws, and rules and regulations of the San Joaquin Local Health District: Home owner or Licensed agentas 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 ins tions. Complete drawing on reverse side. Signed X Title: Date: 5^ /:2 _;7 FOR DEPARTMENT USE ONLY Application Accepted by / Date Arua 51 Pit or Grout Inspection by bate Final Inspection b 7 Date Additional Comments: ❑ Silk 466-6781 ❑ Lodi 369-3621. ❑ Manteca 823-7104 C] Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazolton Ave., P.O. Box 2008, Stk., CA 95201 EEE AMOUNT DUE AM6UNT REMITTED RECEIVED BY INFO C DATE PERMIT'NO. 3"24(REV.i i e s)