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1 APPLICATION FOR PERMIT t SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephohe (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED t (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 weii/pump and the Rules and Regulations of the San Joaquin Local Health District. ' / W�1 City Lot Size�� PM 6 Jab Address r v \\ �r�_lLLlw� 1?iiL\i 1L� ..Adrtres� 1�� LL� _ _ Phone tlOvner 5 l�fil!��e - �i E Contra t- lr4 f Address -f _ Lic nse N�-604S 6 Phone .rTYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION f PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom Q Manteca Dia. of Well Excavation Dia. of Well Casing ` ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'] Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout _ I 1 Irrigation —.-Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50'1 -- TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIRlADDITION l I DESTRUCTION l I Wo septic system permitted if public sewer is available within 200 feet.) BUJ Installation will serve: Residence_ Commercial_ Other vi I T Number of living units: Number of bedrooms VI Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal (� Distance to nearest: Well Foundation Property Line ti I LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size t _ Number t r SUMPS LI Distance to nearest: 11 Well Foundation Property Line DISPOSAL PONDS ❑ r I s l -r 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 r rules and regulations of the San Joaquin Local Health Di§trict. 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 mus call for all requ' inspections. Complete drawing on reverse side. Xigned X — Title: �� Date: O F DEPARTMENT USE ONE Application Accepted by a y jDate �� ID Area Pit or Grout Inspection by Date Final Inspection by T Date7o N r � Additional Comments: ` ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ 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 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO I +.EH 13-24(REV.t i x sl a� .-�� EH 14-26 �',�fV Op. �y , i-/q0 q0" O