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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601.E. HAZELTON AVE., STOCKTON, CA r Telephone (209)'466781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED .L.`. (Complete in Triplicate) r 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.649 for sewage or No.:1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. ' l �d 47 ��Ta LU O -0e12 � l J4' PM Job Address City �� X -t Size Owner's Name Ca z11W Address .._ __ �M Phone 7cq Contractor /c-Q Address C��9y-TVZ/ZL�cense No. Phone Phone��/� TYPE OF WELL/PUMP: NEW WELL n WELL REPLACEMENT O DESTRUCTION ❑ PUMP INSTALLATION U.� �; 041 : , SYSTEM REPAIR F1 OTHER ❑ t DISTANCE TO NEAREST: SEPTIC TANK -SEWER-LINES DISPOSAL FLD. PROP. LINE j FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA -,CONSTRUCTION SPECIFICATIONS I , Industrial ❑.Open Bottom O Manteca I Die sof Well Excavation__.._.., _ Dia..of Well Casing C Domestic/Private ❑ Gravel Pack 0 Tracy � J- Type of Casing Specifications C Public ❑ Other ❑ Deltas Depth of.Grout Seal Type of Grout I C Irrigation _Approx. Depth , ❑ Eastern Surface-Seal Installed by j Repair Work Done 7 Type of Pump _ .1/H.P. `- State Work Done Well Destruction J Well Diameter Sealing Material(top 501 Depth Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION U DESTRUCTION ❑ (No septic system permitted if public sewer is v available within 200 feet.) Installation will serve: Residence_ Commercial_ Other t r Number of living units: _T_._ Number of bedrooms Character of soil to a depth of 3 feet: .._... Water table depth SEPTIC TANK J Type/Mfg __ Capacity No. Compartments _ PKG. TREATMENT PLT. 7 Method of Disposal Distance to nearest: Wahl Foundation Property Line ,IV LEACHING LINE d6 No. & Length of lines r � �T Total length/size I......__ FILTER BED ❑ - .Distance to nearest: Well it-�'4 Foundation 3 a Property line SEEPAGE PITS Depth -Size -7�' Number r 1. SUMPS C Distance to nearest: Well __ Foundation_ Property Line DISPOSAL PONDS L: t r 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."Contractors hiring or subcontracting signature certifies the following:"I certify that in the performance of the work for which this permit Is issued,I shallemploy persons subject to workman's compensa- tion laws of California." .r The applicant must ca or all required' oE plate drawing on reverse side. r a Signed Title: � 4 Date: FOR DEPARTMENT USE ONLY Application Accepted by Date• 4rea Pit or Grout Inspection by / Date Final Inspection by R. _ Date J A Additional Comments: G Stk 466-8781 ❑ Lodi. 369-3621 CJ Manteca 82.3-7104 _ U Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 IN AMOUNT DUE AMOUNT REMITTED CCK RECEIVED BY DATE PERMIT'NO. +EH 1321(REV.i'e e; —y /:�_� EN W26