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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T 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 �z_T� 0,2el` k el, ea City S o',C '• Lot Size PM Owner's Name 60 ,+e I.iFa f•-@ C;.Af ja- Address1��(� ��Phone Contractor ' ? Address License No. Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEME ❑ DESTRUCTION j PUMP INSTALLAT1 U-J l SYSTEM REPAIR ❑ OTHER O DISTANCE TO NEAREST: SEPTIC TANK 2d ' SEWER LINES .Q 7.4 DISPOSAL FLD. .2-74 9PROP. LINE .2- ' FOUNDATION —os� � AGRICULTUREWELL 1 s OTHER WELL PITS/SUMPS.2Z 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-4 Ll C Specifications /6d M Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout _ 1>4Irrigation __Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump s�� H.P. ;210 State Work Done c \ Well Destruction ❑ Well Diameter Sealing Material (top 501 '1,1w � 111 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) J 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. ❑ 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 SEEPAGE PITS 11 Depth Size _ Number 1 Z_ SUMPS Ll Distance to nearest: Well _ Foundation 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 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 re wired in tions. omplete drawing on reverse side. Signed X Title: 211 &LDate: J FOR DEPARTMENT USE ONLY Application Accepted by Date i Area d Pit or Grout Ins '/ Final Inspection by Date / CAPDK�cant_- al Comments: r 1� S Q Cm li "1Y 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Return all copies to: Environmental Health Permit/Services 16-01,E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMTTED CASH CK RECEIVED BY DATE PERMIT'NO. ♦.EH 13.24(REV.1/"5) t EH 1428 ' -- • II