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APPLICATION FOR PERMIT y- 1 SAN JOAQUIN LOCAL HEALTH DISTRICT 1 1601 E. HAZEL T ONVE., STOCKTON, CA Telephone 209) 466-6781 G✓ p- f PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Yy Application is he+eby 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 • C Lot Size PM Q/ (J Vl0L Address 93 t? ! 51Le "1� ' Phone 6 Z Owner's Name 7 "1 f �, r l�� gf Vr Lic�nse Note Phon Contractor � I K Address TYPE OF WELL/PUMP: NEW WELL'-` WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION O SYSTEM REPAIR O OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK - SEWER LINES X;5-70 / DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Industrial PQ Type of Casing Specifications rr �Qomestic/Private .Z[,Gravel Pack E3 Tracy 9 f'I Public Other ❑ Delta Depth of Grout Seal ..� t Type of Grout I I Irrigation ._-Approx. Depth I I Eastern Surface Seal Installed by I - Repair Work Done ❑ Type of Pump H.P. State Work Done _ Sealing Material (top 50'1 Well Destruction El . Well Diameter Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION 1.1 DESTRUCTION I 1 available(No serw tfeet.)200 feetsystem permittedrf public sewer is C Installation will serve:. Residence_ Commercial— Other Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: . sem,,. .., ... ... �,.c_-- -�r4+-Capacity-,_�r ;S�rallo. Comm �r ' L'SEPTIQ_TANK -^'__ 'p"'Type1°Mig_'- odi7 - ' Meth PKG. TREATMENT PLT. ❑ �K Distance to nearest: Well Foundation Property UnRECE 1F E D . LEACHING LINE L1 No. & Length of lines Total length/size i�,JOAQUIN COi1NTY f FILTER BED ElDistariEd'to nearest: Well Foundation Prop emdfiIC-HEAtTFI-S£RVICES Size Number SEEPAGE PITS l I Depth Property Line ,SUMPS Ll Distance to nearest: Well Foundation 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: "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,1 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. �y7 IN Signed X � Title: Date: FOR DEPARTMENT USE ONLY ;w 9 Date Area Application Accepted by // Pit or ro Inspection by Date��Final Inspection by :t- Date 1L1 -� ( Additional Comments: ElStk 466-6781 O Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-638P5 �tk., CA 95201 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P:O BeL, FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO —y ,/y p S EH 13-241REV.ii a5) / �.Ar. ` I , '�/�o Q_-, O