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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT v 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 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 in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for welllpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address City Lot Size PM Owner's Name Address es-� �l Phone �L"� -- Contractor AddresspF/• � License Phone / �/6 66 TYPE OF WELL/PUMP: DISTANCE TO NEAREST: INTENDED USE [I Industrial ❑ Domestic/ Private r Public I i Irrigation Repair Work Done ❑ Well Destruction ❑ NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ TYPE OF WELL ❑ Open Bottom ❑ Gravel Pack L] Other --Approx. Depth Type of Pump — Well Diameter Depth PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Manteca Dia. of Well Excavation ❑ Tracy Type of Casing ❑ Delta Depth of Grout Seal I 1 Eastern Surface Seal Installed by— H. P. yH.P. State Work Done Sealing Material (top 501 Filler Material (Below 501 Dia. of Well Casing Specifications Type of Grout TYPE OF SEPTIC WORK: NEW INSTALLATIONpf% REPAIR /ADDITION I i DESTRUCTION I I iNo septic system permitted if public sewer is % available within 200 feet.) Installation will serve: Residence Y Commercial _ Other Number of living units: J Number of bedrooms Z Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK �4 Type/Mfg Capacity 4&?�, No. Compartments _ PKG. TREATMENT PLT. ❑ 1 Method of Diso sal _ Distance to nearest: Well Foundation __- Property Line LEACHING LINE , No. & Length of lines Tytal length/size FILTER BED ❑ Distance to clearest: Well Foundation �� f- Property Line S�4" 67 SEEPAGE PITS ' Depth _ ��_ __Size Number l d, SUMPS L] Distance to nearest: Well �Foundation 119 f_ Property Line DISPOSAL PONDS ❑ 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." 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, I shall employ persons subject to workman's compensa- tion laws of California." The applicant t cMar quired ' pectin s� Complete drawing on re se sift. Signed X I Title: __ __ Date: 1014V F DEPARTMENT USE ONLY [J Application Accepted by Date `' r _ `� ` ' Area �/ � � � Pit or Grout Inspection by Date Final Inspection by _ . Gf,&_,1- .1,&_ Date �p Additional Comments: S . / Li_+- f!G C S *.v- D :;;e !=</ LEACHING LINE , No. & Length of lines Tytal length/size FILTER BED ❑ Distance to clearest: Well Foundation �� f- Property Line S�4" SEEPAGE PITS ' Depth _ ��_ __Size Number l d, SUMPS L] Distance to nearest: Well �Foundation 119 f_ Property Line DISPOSAL PONDS ❑ 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." 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, I shall employ persons subject to workman's compensa- tion laws of California." The applicant t cMar quired ' pectin s� Complete drawing on re se sift. Signed X I Title: __ __ Date: 1014V F DEPARTMENT USE ONLY [J Application Accepted by Date `' r _ `� ` ' Area �/ � � � Pit or Grout Inspection by Date Final Inspection by _ . Gf,&_,1- .1,&_ Date �p Additional Comments: S . / Li_+- f!G C S *.v- D :;;e !=</ ❑ Stk 488-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 _ A Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 fEE AMOUNT DUE AMOUNT REMITTED t n � RECEIVED BY DATE PERMIT -IVO. INFO �7� CASH ♦ EH 13-241REV. IiR5l o f]PopId/f EH 14-28 v