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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. � ( t Job Address City 4� Lot Size PM Owner's Name 4 c' 4D adL Address hone Contractor /4.11d Address C� License No Phone i TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE F FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Lndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I-I Public ❑ Other ❑ Delta Depth of Grout Sealf Type of Grout I I Irrigation ___Approx. Depth l I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 50') N lit Depth Filler Material (below 50') `TYPE OF SEPTIC WORK: NEW INSTALLATION I.l REPAIRJADDlTION DESTRUCTION € I (No septic system permitted if public sewer is available within 200 feet./ Installation will serve: Residence Commercial_ Other _ f ..-._- Number of living units: Number of bedrooms � t r Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity._.A� _ No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal l• -- —Distance-to-nearest: Well Foundation Property Line LEACHING LINE F No-.,A Length'of lines P 1, , ,.,,,.. Tota! length/size FILTER BED ❑ Distarice to nearest: Well/o Foundation -Ael _ Property Line_Co 1*1�J I , SEEPAGE PITS l I^ Depth Size �Number SUMPS t/ Distance to nearest: Well 'Foundation Property Line 1-,-% (j DISPOSAL PONDS ❑ l�L.d +� 1 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 Dikrict..:, 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 t6 workman's comWsation'laws of California."Contractors hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,.)shall employ persons subject to workman's compensa- 'tion'laws of California," ?,r ,- - n Thetapplicant-must call for all required inspections:Complete drawing on'reverse side. Sighted X •r Title:< r wry Date: f ` R DEPARTMENT USE ONLY i t Application Accepted by p/ Date /'z Area Pit or Grout Inspection.by pDate-V-3 ^' . Final Inspection by Date�� . 4 z F'• Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca ' 823-7104 ❑ Tracy 835-6385 n . Applicant - Return all copies to: Environmental Healteimit/Services 1601 E. Hazelton AJe., P.O. Box 2009, Stk., CA 95201FEE 'INFO' - AMOUNT,bUE ,..` AMOUNT I�MITTED CK CASH RECEIVED RY DATE _ PERMI7'NO. s. +.EH 13-24 IREY.i/,n 51 '-- EH 14-28 '�