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I ✓ l APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE i ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM_DA_ TE_ 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. 18b2 for well/purnp and the Rules and Regulations of the San Joaquin Local Health District. Job Address ! CityCLSize %1 [-PM Owner's Name _.-__ Address [/ /� --- -- ------- - Phone"" Contracto/�/ 4� ' 6 Address 5^ / ! License NoT �Phone 1K 2�z TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION G PUMP INSTALLATION` &r, SYSTEM REPAIR ❑ OTHER L: DISTANCE TO NEAREST: SEPTIC TANK �L& SEWER LINES DISPOSAL FLD. PROP. LINE ecu FOUNDATION �//a1/ AGRICULTURE WELL OTHER WELLPITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO S { ��jQ! - gfr�ury44, ❑ Industrialpen Bottom ❑ Manteca Dia- of Well Excavation- 411 Zo — Dia of Well Casin mestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing„� � SpecificationsIla -d4� FI Public r Other f- Delta Depth of Grout Seal __.5�_ _ _- /e of Grout _ I r I I Irrigation ��Approx. Depth �I I EB rn Surface Seal Installed by Q Repair Work Done -] Type of Pump S_ State Work Done — -- _ Well Destruction ❑ Well Diameter _.__..... Sealing Material flop Si \ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION t I DESTRUCTION I INo septic system permitted if public sewer is available within 200 feet./ Installation will serve: Residence Commercial . . . Other _ _-_ N, 1 Number of living units: Number of bedrooms J I I Character of soil to a depth of 3 feet: _- _—_..... Water table depth -'SEPTIC TANK - Ll Type/Mfg Capacity__ No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well _ . _ Foundation _ ._ ._._ Property Line LEACHING LINE LI No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation __ Property Line SEEPAGE PITS I I Depth Size _ Number SUMPS (l Distance to nearest: Well Foundation Property Line DISPOSAL PONDS iJ I hereby certify that I have prepared this application and that tho work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Hoare 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 r certifies the following:"I certify that in the performance of the work for which this permit is issued, I shalt employ persons subject to workman's compensa- tion laws of California." The applicantmust all for all required inspections. Cor et drawing on reverse side. J ��/ Signed X Dom/ 4 r Title: _ � Date: FOR DEPARTMENT USE ONLY App":ication Accepted by Date ✓ Area Pit or Grout Inspection by Date _ Final Inspection by Date _ Addaionel Comments:, LJ Stk 466-6781 L7 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 836-6386 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 l' FEE AMOUNT DUE , AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO . EH3-I4 IREV.t,Ml,i - �A g8 ��4 i EH 4-2e b 513 0 8