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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL�HEALTH DISTRICT 1601 E. HAZEL I ON AVE., STOCKTON, CA Telephone 12091-466-6781 PERMIT EXPIRES 1'YEAR'FROM,DATE ISSUED:' )::r' ` ICohiplete 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 Ryles and Regulations of the San Joaquin 57, Local Health District. • 9 �; rrC`� Lot Size ►. PM ' Job Address City Owner's'Name ddress= N',—.,Phone Contractor Address License No. w Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. ^ PROP. LINE ' i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS v } ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia'of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing "Specifications t ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done $ Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATIONX REPAIRIADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is available within 200 feet.)•`v° ! , I ! Installation will serve: Residence— Commercial— Other I Number of living units: Number of bedroomsl Character of soil to a depth of 3 feet: Water table depth! �' 1fJ I k Capacity?- 0 No. Compartments SEPTIC TANK El Type/Mfgt �L' PKG. TREATMENT PLT. ❑ Method of Dispdsal 3 Distance to nearest: Well�� Foundation= Property Line ^Tr LEACHING LINE No. & Length of lines-- - ' '. Tptal length/size �'�r FILTER BED ❑ Distance to nearest: Well Foi n6wion _Property Lines!' 3 i Number ""- SEEPAGE PITS - ❑ Depth Size € SUMPS _ ❑ 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 District. I i 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 i e employ any perso 1n uch manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature I certifies the Poll ing: I certify that i e performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa C tion laws of lifomia. ' I The applica m or all r r inspections. Complete drawing on reverse side. j Signed Title: OAI Date: 4 FOR DEPARTMENT USE ONLY I Application Accepted by Date 7 Area � Pit or Grout Inspection by Date Final Inspection by Date Additional CommentsCy /ter I C1Stk 46Cr6781 ❑ Lodi 369-3621 LJ Manteca BM-7104 El Tracy 56365 i Applicant- Return all copies to: Environmental ��eaI h Per it/Serv1�q� 1601 E. Hazelton Ave., P.O. Box 2009, 5tk., CA 95201 �► o I C Ala? G1JQ c�7 8 ice+ i Ste* FEE I INFO AMOUNT DUE AMOUNT REMITTED CK# RECEIVED BY DATE ' PERMIT"NO. ./� k + EH 13-241REV.1/851a `� ®� - - - - EH 14-26 L {