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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. TMs application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No.1862 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District, Job Address U ✓ Ci ` `' Lot Size� °/Z PM Owner's Name , Address �t Phone ✓-z 1/2 7 /Y Contractord". Addressffi—+74_ _ - License No3_1,f(2Z 6 Phone TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT F- DESTRUCTION '❑ PUMP INSTALLATION i] SYSTEM F#EPAIR C OTHER 7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES' DISPOSAL FLO. PROP. LINE FOUNDATION \ AGRICULTURE WELL OTHER WELL___ _- . PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial LL Open Bottom ❑ Manteca pia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private 5 Gravel Pack U Tracy r Type of Casing Specifications ❑ Public ❑ Other -Gl Delta �. Depth of Grout Seal Type of Grout Irrigation ---Approx, Depth! CEastern - Surface Seal Installed by Repair Work Done ❑ Type of Pump H,P, - State Work Done Well Destruction O Well Diameter Sealing Material(top 50') _ Depth F' Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ -�REPWR/ 'DDITION LI DESTRUCTION❑ (No septic system permitted if public sewer is j / available within 200 feet.) Installation will serve: Residence r Commercial_ Other Number of living units: Number of bedrooms__ Character of soil to a depth of 3 feet: l _._ WateF.tabig depth �S SEPTIC TANK Cif Type/Mfgl _ .prLltcGd Capacity 14-4-e, No. Compartments Q PKG:'TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation__ Property Line LEACHING LINE Lff"'No. & Length of,,lines Total length/size FILTER BED ❑ Distance-Y n a$st: Well_Sa/ Foundation_ '_ Property Line._ SEEPAGE PITS Depth A5,Zjt Size �3 �� Number SUMPS ❑ Distance to nearest: Well 1&6 / FoundationT 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 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 fhe 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 X6• / Title: Date: R DEPART E SE ONLY r Application Accepted by � 4 Date Area /r Pit or Grout Ins-pe/ction by - ^h pate Final Inspection by�J rye�yDate 7 Additional Cor r� ts: Y� V y � '�` CA Ay �'K WOW a ❑ Stk 466-6781 ❑ Lodi 369-3621 C Manteca 823-7104 ❑Tracy 8X6385 Applicant-Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA'95201 IEEENFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DCK 9 ATE PERMR NO. ♦ EM 13-241REV.1,551 EH 1426