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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 . . y y ' .,,,,,,.-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. Job Address '3q ! S�'f ! J a� �, Cit Th7� �� 4CrGS PM l Y Lot Size !, OwneO r r's Name Address 3 ©� sl �/l b/ Phone 9 7 8-51-7 Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION j SYSTEM REPAIR EDOTHER ❑ I DISTANCE ISTAN EC EC TO NEAREST:.SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE 1 TYPE OF`WELL PROBLEM AREA CONSTRUCTIO'N`SPECIFICATIONS ❑ Industrial EJ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation pprox.:Depth ❑ stern Surface Seal Installed by Repair Work Done C1 Type of Pump Sar. H.P. 1 State Work Done Well Destruction 1-1 Well diameter r! lJ' c Sealing Material (top 50') Depth i Filler Material IBelow 50') 10 a TYPE OF SEPTIC WORK: NEW INSTALLATION L1REPAIR/ADDITION El DESTRUCTION Ll (No septic system permitted if public sewer is 1 available within 200 feet.) Installation will serve: Residence = Commercial— Other Number of living units: Num'b'er of bedrooms Character of soil to a depth of 3 feet ---- -- =' ' _ Water table depth , SEPTIC TANK ClType/Mf �� x 1 g Capacity t No. Compartments PKG. TREATMENT PLT. ❑ Method of Dispose! Distance to nearest: Well Foundation I Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest:. Well Foundation Property i Line SEEPAGE PITS C7 Depth I I Size /f Number I SUMPS _ -4- El Distance o nearest: Well Foundation Property Line DISPOSAL PONDS O � I hereby'certify that I have prepared this application and that thew ork'wiII',be done'in'accordarice with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signatuee 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 mannenas 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, 1 shall employ persons subject to workman's compensa- tion laws of Calif The applic must c for all required ins ctions. C plete drawing on reverse side. ± -� Signed f Title: Date: L 11i FOR DEPARTMENT USE ONLY Application Accepted by `""""- r T ?k Date: Area v Ir Pit or Grout Inspection by f Date Final Inspection-by. Date Additional Comments: k � ❑ Stk 466-6781 C1 Lodi 369-3621, ❑ Manteca 823-7104 ❑ Tracy 635-6385 I Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE i k INFO AMOUNT DUE AMOUNT REMITTED CAM",, RECEIVED YY .DATE PERMIT'NO. ! } e ♦ EH 13-24{REV.i i R s) --- ` +�� /� �� EH 14-ZB +� 1