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i APPLICATION FOR PERMIT `+ SAN JOAQUtN 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 hoteby made 10 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. CC Joh Address ) ._E-xy,. City Lot Size PM Owner's Name J�/(1._ Address � . Phont 191 COntractoroG Address�(/ License No.✓ /6tG TYPE OF WELL!PUMP: NE WELL WELL REPLACEMENT L. DESTRUCTION LJ PUMP INSTALLATION O SYSTEM REPAIR G OTHER L-` 3 M J 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 ndustrial C Open Bottom U Manteca Dia. of Well Excavation Dia. of Well Casing F. Domestic!Private DR"Gfavel Pack ❑ Tracy Type of Casing Specifications � // ��^^ I'i Public ''Other , U Delta Depth of Grout Seal llc% �._.. Type of Gr0ut�`�� I ; Irrigation _` Z>Approx. Depth I Eastern Surface Seal Installed by Repair Wotk Done D Type of Pump _ H.P. State Work Done Well Destruction 0 Well Diameter ry Sealing Material Itop 501 Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ! I DESTRUCTION I (No septic system permitted if public sewer is available within 200 feet.) 1 installation will serve: Residence_ Commercial _ Other Number of living units: Number of bedrooms V Character of soil to a depth of 3 feet: _._.__ Water table depth C SEPTIC TANK O Type!Mfg Capacity No. Compartments PKG. TREATMENT PLT. CJ Method of Disposal Distance to nearest: Well Foundation Property Line r LEACHING LINE 1 No. & Length of lines Total length/size .__ _ FILTER BED U Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS 1- Distance to nearest: Well Foundation __. Property Line DISPOSAL PONDS Cl 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 subinct to workman's compensa tion laws of California." The applic t I for all required inspections. Complete drawing on reverse side. Signed _ Title: _13CIJ' Date: Q ZC1 EP T USE ONLY Z— ?7� Application Accepted by Date _. Are, Pit or Grout Inspection by _ __ Date 7- __— Final Inspection by Dat�,��-e Additional Comments: ❑ Sik 466-6781 O Lodi 369-3621 L; Manteca 823-7104 O Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO { +� Q . EH 1321 fREV.1/4 51 3 S 0 c, I G / 7 1 EN 14-2e