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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA 1 ,I Telephorne (209) 466-6781 +._ PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I (Complete in Triplicate) Application is hereby made to the Saf Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance withSan,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.' Job Address i -e City Ci 16✓) Lot Size PM i II Owner's Name �f V��1 Address �`"��'0'' Phone Contractor Address "00 p -License No. Q Phoney 'Lf.a TYPE OF WELL/PUMP: .,NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION E ! "` PUMP INSTALLATION ❑ SYSTEM REPAIR,O 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 '�^ ❑ Industrial ;� O Open Bottom -❑ Manteca _r,.Dia. of Well•Excavation Dia. of Well Casing ❑,Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1-1 Public Cl Other n Delta Depth of Grout Seal Type of Grout I 1 Irrigation I __Approx. Depth l I,Eastern !Surface Seal Installed by _ Repair Work Done El Type of Pump H,P. { State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth ---- .- Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I'1 REPAIR/ADDITION DESTRUCTION I 1 INo septic system permitted if public sewer is ` available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units I Number of bedrooms�r a "� _. ;,, Character of soil to'a depth of 3 feet: C sri ` ` „ISI Walei table depth SEPTIC TANK ❑ Type/Mfgf r `i Caja it li t PKG. TREATMENT PLT. O �-1`# pr W+ No. Compartments 4 t W. Method of Disposal. Distance'to:,nearest Well1� Foundatloll r Property Line LEACHING LINENo & Length of lines i. `~�f) 'FF'" Total length/size r r f FILTER BED ❑ I)stance to nearest: Well Foundation Propeity Line ` SEEPAGE PITS I 1 '<Depth i X Size- 14,� /, � Number SUMPS-- - - V Distance to nearest: Well Foundation Pro: gry Line DISPOSAL PONDS ❑ 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. i 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 t; certifies the following: 1 certify that id the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." i The applicant must call for all 1equired inspections. Complete drawing on revetse'side. Signed X—..- Title: Date: Ld 13/2, DEPA MEN7 USE ONLY r 4 Application Accepted by j Date Area / Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: .?rr I❑ Stk 466-6781 EJ Lodi 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, Stk., CA 95201 FEE INFO AMOUNT DUE' AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMiT'NO. +.EH 13-24{REV.I i a 51u'` Q A EH 14-29 Q 5 8 1