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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.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 Districts // � �/ Job Address �L `6W'e< City dil Lot Size / PM Owner's Name io 2 Address , A' 1`3t> [ Phone S rot Contractor's Name License No. 0 1 7 a-� Phone 30&3 -3 3 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION C 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 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing * Domestic/Private Ll Gravel Pack Ll Tracy Type of Casing Specifications ❑ Public :1 Other -1 Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by U Repair Work Done ❑ Type of Pump H.P. _� State Work Done Well Destruction C Well Diameter Searing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION1,-'REPAIR/ADDITION C DESTRUCTION ❑ (No septic system permitted if public sewer is r available within 200 feet.) I Installation will serve: Residence_ Commercial Other a C Number of living units: Number of bedrooms Q r Character of soil to a depth of 3 feet: Water table depth `� A SEPTIC TANK rL!Type/Mfg Capacity ��flA No. Compartments 21 PKG. TREATMENT PLT. C �7 Method of//Disposal Distance to nearest: Well �UI Foundation s _ Property Line L .+ LEACHING LINE C' No. & Length of lines V0 1 al length/size ] FILTER BED ❑ Distance to nearest: Well�0� Foundation Pr I aperty Line 3 SEEPAGE PITS ✓Depthrt�S Size 136 Number C `1 SUMPS Distance to nearest: Well�t00 Foundation 9 1:5 Property Line G 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."Contractors 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 callbyequired inspections. Complete drawing on reverse side. v Signed __ Title: u9:v Date: , / R DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by ` DM?—//— Additional te —//-Additional Comments: ❑ Silk 465-6781 C Lodi 369-Ml ❑ Manteca 823-7104 ❑ Tracy 831>SM Applicant- Return all copies to: Environrt»ntal Health Permit/Services 1801 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED (.CASH EH 14-MRECEIVED BY DATE EERT NO. +EH 1 344 lREV.101831 t Li 1.�