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APPLICATION FOR PERMIT SAN JOAQUIN .LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM .DATE ISSUED (Complete in Triplicate) r� 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 Rules and Regulations of the San Joaquin Local Health District: - ..i *• .f t " Job Address 31 a S .C' "`" City Lot Size PM 1 p Address I`y 0� A)' �/`^'� Phone Owner's Name " " Contract Address—tom 6'7 r License Phone TYPE OF WELL/PUMP: NEW WELL LJ REPLACEMENT ❑ DESTRUCTION El PUMP INSTALLATION ❑ SYSTEM REPAIR 171 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS l INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS El Industrial L1 Open Bottom 171 Manteca Dia. of Well Excavation Dia. of Well Casing ` ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern . Surface Seal Installed by i Repair Work Done C1Type of Pump H.P. State Work Done _ { Well Destruction ❑ Well Diameter _Sealing Material (top 501�, -_-_- - --eptly �— � Filler Material (Below 501, f TYPE OF SEPTIC WORK: NEW INSTALLATION 9-IREPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is available within 200 feet.) . --lnstallation-will-serve:--Residence=C-ommercial----- Other r Number of living units: Number of be r oms i Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg (Capacity laD© -)No, Compartments PKG. TREATMENT PLT. ❑ < Method of Disposal Distance to nearest: Well 50 Foundation,O Property Line -- . k LEACHING LINE L��No. & Length of lines f '" ! Total 1 ngth/size X < c r FILTER BED EJ Distance to nearest: Well Foundation !O Property Line s SEEPAGE PITS a 6--Depth 1:2'IT- 3 !Number _ SUMPS ❑ Distance to nearest: Wel! D0`. Foundation Cpl "^=Property tineIS 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 thatin 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 compensationlaws of California."Contractors hiring or sub-contracting signature certifies the following:"I certify that in the performance of the-work•for.which-this.efmit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant mu call for al equir d inspections. Complete drawing on reverse side. . }/ y Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by -' Dater f Area n or Grout Inspection�by Date f�� _ Final Inspection by /fes Date1�`� � Additional Comments. O 5tk 4664781? ' ;❑.Lodi 369-3621 ❑_Manteca $23-7104 ❑ Tracy .83556385 Applicant - Return all'copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.;-P_.O. Box 2009. Stk., CA 96201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY' DATE PERMIT NO. INFO �/g + EH 13-241REV.1/851 r EH 1429