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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application is heaeby 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 � __ I " If, City .5 r!f7�/Lot Sir.Z 4I7 V 7 PM Owner's Narrow �Addrtress}' ' Phone Contractor v/� y Address ` License Na, Phone f TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT L1 DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK, SEWER LINES DISPOSAL FLD. PROP. LINE (� FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS N INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private C] Gravel Pack ❑ Tracy Type of Casing Specifications j M Public CI Other 171 Delta Depth of Grout Seal Type of Grout -- I 1 Irrigation _.-Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done 0 Ty a of Pump H.P. State Work ne Well Destruction Well Diameter Sealing Material Itop 50'1 -- Depth Filler Material lBelow 501 _ _ - TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.) Installation will serve- Residence— Commercial_ Other 1 Number of living units: Number of bedrooms r Character of soil to a depth of 3 feet: Water table depth } SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments a PKG. TREATMENT PLT. 1-1Method of Disposal .� 3 a 1 Distance to nearest: Well Foundation Property Line LEACHING LINE 11No. & Length of lines `bTotaliengthlsizer FILTER BED 0 Distance to nearest: Well Foundation '-.Property Line ...a. s SEEPAGE PITS l I Depth Size Number - # SUMPS ❑ Distance to nearest: Well Foundation Property Line ? DISPOSAL PONDS C] +► 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 j rules and regulations of the-San Joaquin'Local Health District. 19 �,. Home owner or licensed ageni'-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 sig a re certifies the fallowing: "I certify that in ther'for'hce of the work for which this permit is issued, I shall employ persons subject to workman_'-s'`compensa- tion laws of California." The applicant must call for all required inspectio s..Complete drawing on reverse side. f t" Signed !? Title: "ri- _ Date: FOR DEPARTMENT USE ONLY r r 7 r3-� Application Accepted by t Date Area, a k � Pit or Grout Inspection by ate Final Inspection by Date Additional Comments: } ❑ Stk 466-6781 ❑ 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 20M Stk., CA 95201 ' �. 1 I FEE INFO AMOUNT DUE,_ AMOUNT,REMlTTEO. CASH RECEIVED BY- ;DAT PERMIT NO. f - �` ! r EH t}241REV.iiNSY F EH 14-26 .. . ` 4 y