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APPLICATION FOR PERMIT �\S SAN JOAQUIN LOCAL HEALTH DISTRICT P ' 1601 E. HAZE i ON AVE., STOCKTON, CA Telephone (209) 466-6781 1 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 of No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. / Job Address - `—" lid City_-J�/7Lot Size PM _ Owner's Name �_. 1 `"'Ad ess G Sj�C-.�•�c�'� � Phone Contractor --Address—., _License No._ _- Phone TYPE OF WELL/PUMP: NEW WELL L WELL REPLACEMENT F1 DESTRUCTION ❑ _. PUMP INSTALLATION L; SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK .- SE LINES POSAL FLD._ PROP. LINE FOUNDATION AGRICUL RE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CO T TION SPECIFICATIONS ❑ Industrial O Open Bottom O Manteca i . 0 ell Excavation Dia. of Well Casing _ - I� Domestic;Private (-1 Gravel Pack I-1 Tracy Type of Ca ' g Specifications ('1 Public (_1 Other Cl Delt Depth of Grou eal _ Type of Grout_—____ I Irrigation __-Approx. Depth astern Surface Seal lnsta by Repair Work Dune tl Type of Pump H.P. _ State Work Done Well Destruction L Well Diameter - Sealing Material (top 50'1 Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDIIION I DESTRUCTIO (No septic system permitted if public sewer is I 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 G SEPTIC TANK 1—i Type/Mfg _ Capacity_- No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal G Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. &Length df lines Total length/size _ �. FILTER BED 7`1 Distance to nearest: Well _ Foundation Property Line SEEPAGE PITS I I Depth Size _ Number SUMPS LI Distance tc nearest: Well_- Foundation _ Property Line _ DISPOSAL PONDS D 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, 1 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 0 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 applica ust call for all reguired inspections. Complete drawing on reverse side. Signed X ��_ �� Title: Date: Z �Lx'� !-�U ala► FOR DEPARTMENT USE ONLY Application Accepted by _ Data��_O / , Area v Pit or Grout Inspection by�,'� � S t_ _- Da-tee_ Final Inspection by );11,1/t LL Data 3 O Additional Comments: - L . 1 1. L&l ❑ Stk 466.6781 O Lodi 369-3621 F] Manteca 823-7104 ❑ Tracy 895-6385 G S y Applicant - Return all copies to: Environmental Heatth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 J INFO EE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. . Ertl&24IREY.rine, #,3s, Ob �h � AS ' �J