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t� APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1641 E. HAZEL T ON AVE., STOCKTON, CA Telephone (249) 466-6781 1. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED l (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 City Gam- Lot Size PM Owner's Name QA Address r7 Phone s 1' Contractor 1��-L�� AddressLicense No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION L1 I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ k DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL ?ITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ElIndustrial LIOpen Bottom LlManteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 4� Public--- -- --� -F- Other —9-Delta—K`• -Depth of.Grout Seal Type-of-Grout I i Irrigation _Approx. Depth i I Eastern 5ufface Seal Installed by - Repair Work Done ❑ Type of Pump ,cH.P. State Work Done j- Well Destruction ❑ Well Diameter 'Sealing Material (top 501 Depth Filler Material (Below 501 — • l - TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I 1 DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet) Installation will server Residence Commercial f� Other Number of living units: Number of bedroomsj � t' " S s Character of soil to a depth of 3 feet: e� ' '' `� -- Water table deptli r SEPTIC TANK ❑ ,Type/Mfg ' 'Capacity No. Compartments C) i PKG. TREATMENT PLT. ❑ " is t i I� 'w*. +� Method of Disposal Distance°to nearest: Well Foundation �` Property Line l LEACHING LINE ❑ No. & Length of Iines ;Total length/size `FILTER SED Distance to nearest: Well Foundation Property Line SEEPAGE PITS i 1 Depth { Size Number SUMPS ❑ Distance to nearest: Well Foundation "` Property Line- DISPOSAL ine-DISPOSAL PONDS ❑ t 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 i rules and regulations of the San Joaquin Local Health District. h ' Home owner or licensed agent's signature certifiesthefollowing: "I certify that in the performance of the work for,whicti this permit is issued, I shall not f employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I cartify',that in the performance of the worl€for which this permit is issued,I shall employ persons subject to work"man's compensa- tion-laws of California." x- ' The applicant must call for #equir inspectio s.-Complete drawing on reverse side.' -29 ..Signed X Title: bate: FAR DEPARTMENT USE ONLY 167 Application Accepted by Date Area Pit or Grout Inspection by t Date Final tnspection by Date 12 Z If Additional Comments: ❑ Stk 466-6781 _ ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 935-6385 Applicant - Return all copies to: Envirorimental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 �yt� .�FEE� —AMOUNT DUE— "AMOUNT REN11TfED CK' "'RECEIVED'(iY � —DATE-0 —PERMIT-NO. C - INFO CASH '13-241REV.i/n5l - Az>IZ�IM EH 14-26 C> _