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n APPLICATION FOR PERMIT i 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 welUpump and the Rules and Regulations of the San Joaquin p Local Health District. f Job Address r Cit Lot Size�9�/S /x �7.u' PM Owner's Name Address Phone !N ContEact - �Jh o AddieSs' _ - _ Licerise No�7`Z Phone TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ f^. PUMP INSTALLATION ❑ SYSTEMREP IfY❑ OTHER 135 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 4 FOUNDATION AGRICULTURE LL OTHER WELL PITS/SUMPS ' INTENDED USE TYPE OF WELL PROBLEM ARE CONSTRUCTION SPECIFICATIONS i ❑ Industrial ❑ Open Bottom ❑ Mante Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private © Gravel Pa, k ❑ cy Type of Casing Specifications M Public F1 Other Cl Delta Depth of Grout Seal Type of Grout_-_ _. I Irrigation _-Approx epth i I Eastern Surface Seal Installed by - Repair Work Done ❑ Type o ump H.P. -State Work Done I r �3 Well Destruction El Diameter Sealing Material (top 50') Depth Filler Material (Below 501 i TYPE OF SEPTIC ORK: NEW INSTALLATION I 1 REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is I available within 200 feet.] Installation will serve: Residence eV— Commercial_ Other f Number of living units: __/_ Number of bedrooms_ _ r Character of soil to a depth of 3 feet: Water table depth f SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line r LEACHING LINE No. & Length of lines ��10'10 �� Total length/size ( FILTER BED ❑ Distance to nearest: Well Foundation_ Property Line SEEPAGE PITS 11 Depth Sire — — Number SUMPS ❑ Distance to nearest: Well Foundation Property Line t 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. E� 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 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 applican t call fo all i d inspections. Complete drawing on reverse side. Signed Title: Date: -• III, FOR DE PA TMENT USE ONLY ! Application Accepted by rC>_, Date Z _,8, a Pit or Grout Inspection by Date Final Inspection by Date Il Additional Comments: - '❑Stk 466-6791 ❑ Lodf 369-3621- ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 f� I FEE- 'AMOUNT DUE - AMOUNT REMITTED C1< RECEIVED BY DATE PERMIT NO. INFO CASEH H I + 3.24(REV.tiA51 EH 14-26 I CJ