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APPLICATION FOR PERMIT y SAN JOAQUIN LOCAL HEALTH DISTRICT [/ 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 46676781 SCANNEV 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 incompliance 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 0IStfIct. i Job AddressAxe � t. City .5-WA) Lot Size &1'-y/•7n PM Address Contractor Phone Owner's Name Contractor Address 4, til License No. 576 Phone "� 7 TYPE OF WELL/PUMP: NEW WELL F] WELL REPLACEMENT ❑ DESTRUCTION ❑ 1r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ r OTHER ❑ IDISPOSAL FLD. PROP. LINE C DISTANCE Tj0 NEAREST: SEPTIC TANK SEWER LINES +.I - FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 5 Dia. of Well Casing ❑ Industrial�� El Open Bottom ❑ Manteca Dia. of Well Excavation Type of Casing Specifications Ll Domesticl Private ❑ Gravel Pack Ll Tracy Tracy T of Grout E-1PublicElOther ❑ Delta Depth of Grout Seal Type ❑ Irrigation �Approx, Depth Q Eastern Surface Seal Installed by Repair Work Pone ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'),• 01\ Depth epth Filler Material (Below 50'1 F TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIR/ADDITION❑ DESTRUCTION (No septile systeithin m feet)8d if public sewer is �f f Installation will serve: Residence, Commercial, Other MNumber of living units: Number of bedrooms _}} ' Water'table depth Character k f soil to a depth of 3 feet: } il SEPTIC TANK E3Type/Mfg I Capacity No. Compartments I' PKG. TREATMENT PLT. ❑ s f' } Method of Disposal 0 Distance to nearest: Well Foundation `Property Lin V ;-,`��Totat length/size LEAC14ING�k INE � -0--No.E& Length of lines f FILTER BED� ❑ Distance to nearest: R Well Foundation Property Line SEEPAGE PITS ❑ Depth 1 Size n k Number F s SUMPS ❑ Distance to nearest: Well Foundation Property Lin DISPOSAL PONDS ❑ j 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: '9 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 signature certifies the following:"I certify that in the performance of the w ork for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." ¢s I { r The applicant must calk for all required inspections.IC plate drawing on reverse side. Signed Title- � Date: ` IFO�DE RTMENT USE ONLY l / Date Area U Application Accepted by I I Pit or Grout Inspection by Date Final:In�jrspection by Date ~z t Additiona�lComments: //.� x � . ._.. ....��-.,.. _._ ....,... - r .,,.-3 ? ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354385 Applicant'0 Return all copies to: Environmental Health Permit/Services 1601 E.-Hazelton,Ave., P.O.Box 2009, Silk., CA 95201 FEE CK# RECENED SY OATE PERMIT`NO. WFO AMOUNT DUE AMOUNTT REMITTED CASH 77 + EH 13-24{REV.s EH 1428 1