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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE._, STOCKTON, CA I Telephohe (209)'466'6781 PERMIT EXPIRES TYEAR 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 welllpu and the Rules and Regulations of the San Joaquin Local Health District. Job Address City Lot Size PM Owner's Name Address*— �� , M t Phone 4 _4 Contractors dress License '! —?Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ `DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 'dTHER C DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE r H FOUNDATION AGRICULTURE WELL OTHER WELL—e+ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS \ ❑ Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing pp ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1`7 Public ` T f Other ❑ Delta �ry�Depth of Grout Seat+ Type of Grout _ I I Irrigation --Approx. Depth l I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 : Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 17 REPAIR/ADDIrT N I i ESTRU TION I I (No septic system permitted if public sewer is available with' 200 feet.) Installation will serve: Residence_ Commer Lal�_ 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. ❑ I - - _ Method of Disposal Distance to nearest: Well Foundation Property Line r LEACHING LINE ❑ No. & Length of lines s r Total lengthlsize t FILTER BED ❑ `Distance-to nearest: Weil'--,..:..4 Foundation ` Property Line � s I _ SEEPAGE PITS I I Depth € Size I Number }l'� SUMPS r Cl r_ Distance to'nearest^ Well Foundation 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 Disttict. _ 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,t6 become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the'foliowing: "I certify that in the performance of thr e work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." t The applicant usi(call for uired ins tions�Complete drawing on reverse side. all r Signed X Title: Date: FOR DEPARTMENT USE ONLY Application`Accepted by DateA { 1 rea ? Pit or Grout Inspection by \ Date Final Inspection by Date Additional Comments: ❑ 5tk 466-6781 ❑ Lodi 369-3621 *,_0 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 I FEE AMOUNT DUE AMOUNT REMITTED CK INFO CASH RECEIVED BY DATE PEHMIT*NO. . .- r. i +.EHr3-241HEV.iiksl — � " '� EH 74-28 367