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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL'HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Com lete in Triplicate) Y �o 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.549.for sewage or No. 1862 for well/pump and the Ryles and Regulat''Qns of the San Joaquin Local Health District. I -'. �. „ J {6- I iy G�4 /PM Job Address ��(hLL i [ City Lot Size. Owner's Name Address 17{6611 a�• L�7�QLt/�c hone Contractor Address -T5- hR&Aa4 /1 License No.�I��3__ Phone TYPE OF WELL/PUMP: V NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK l00 SEWER LINES DISPOSAL FLD.Z49 PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS C� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONP 10 C1 Industrial Ll Open Bottom El Manteca Dia, of Well Excavation Dia. of Well Casing Domestic/Private Gravel Pack ❑ Tracy Type of Casing pV Specifications ❑ Public El Other ❑ Delta Depth of Grout Seal Typg of Grou ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by LLL I Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ 'Other Number of living units: Number of bedrooms - Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line - S LEACHING LINE �'" ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number �+ SUMPS ❑ Distance to nearest: Well Foundation Property Line r DISPOSAL PONDS w ❑ 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 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 Cal'ornia." The appli a ust call for all requi4 inspections. omplete drawing on a rse side. Signed Title: t Date: FOR DEPA MENT SE ONLY a ' Application Accepted by Date < / Area D� Pit or Grout Inspection by Date Final Inspection b Date — -r Additional Comments:_ ❑ Stk 466-6781 p 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 FEEAMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT`NO. INFO CASH +EH 13-24(REV - / ` EH M26 �� '� 7J �q .