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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 i 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 we{Ilpump and the Rules and Regulations of the San Joaquin Local Health District. r� City .� t�� Lot Size j acPM Job Address AOS IF Owner's Name �•u 1v►llYt W_ f !/1 1 C1/E1 Address "= Phone t \ l 3Contractor ai� ---Address License No. Phone_ V TYPE OF WELLIPUMP: N-rW WELL-❑�"""�-`-WELL REPT ACEMENTJCI"""'"'""""'DESTRUCTION Q"A` # PUMP INSTALLATION ❑ . SYSTEM REPAIR ❑ OTHER ❑ 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 I ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'1 Public r Cl Other _ F7 Delta Depth of Grout Sea! Type of Grout I I Irrigation Approx. Depth t I Eastern Surface Seal Installed by - Repair Work Done ElType of Pump H,P. State Work Dane_ Well Destruction ❑ Well Diameter Sealing Material (top 50')' Depth Filler Material iBelow WIT TYPE OF SEPTIC WORK: NEW INSTALLATION,f REPAIR/ADDITION'I.1 'DESTRUCTION i I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence.-3G Commercial_' Other Number of living units: ff Number of badro ms� _ Character.of soil to a.depth of 3 feet: l� r Water table depth SEPTIC TANK ❑ Type/MfgT r �.� ► `�' Capacity /� No:Compartments PKG, TREATMENT PLT. ❑ �]] �� 77 �. 30 f Method of Disposal F Distance to nearest: WeII J Foundation Property Line , LEACHING LINE ❑ No. & Length of tihes t Total length/size )62 FILTER BED ❑-: Distance to riearest: Well J14191 Foundation., r - Property Line - - tr SEEPAGE PITS l I Depth t' Size Number SUMPS CI Oistance`to near-est. Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will he done in accordance with San Joaquin counly 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'�vhich 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 subject to workman's compensa-, tion laws of California." „. The applicant m t call for all re wired inspections. Co ete drawing on reverse side. / Signed X ` -Title:" Date: A r F EPARTMENT USE ONLY �• Application Accepted by . �_ 4A Date <-1 vv�- Area &--._,,,._ Pit or Grout Inspection by I Date Final Inspection by _m/ m' Date s Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 O Manteca 823-7104 ❑ 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 CK RECEIVED By DATE PERMIT-NO. INFO /C/ASSH + EH 13-24 IREV.i i n a7 7 � t/ / EH 14-26 f