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APPLICATION FOR PERMIT' SAN JOAQUIN LOCAL HEALTH DISTRIC rQj� S 1601 E. HAZELTON AVE., STOCKTON, CA � � , �` Telephone (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. 1B62 for well/pump and the Rules and Regulations of the San Joaquin Local Health Dissttf icct: Job Address *' b City� - Lot Size PM Owner's Name eA � f��f , z-Address / Phone Contractor r" � -Address License No./ 2-3.7 3 Phone TYPE OF WELL/PUMP: _ NEW WELL ❑. WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 4� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES'" DISPOSAL FLO. PROP. LINE ti< FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I INTENDED USE xTYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Y ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing F!?`bomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public ❑ Other 1771 Delta Depth of Grout Seal Type of Grout I I Irrigation —.Approx. Dept1 { I Eastern urface Seal Installed by - Repair Work Done F7^ Type of Pump k H.P. 1+ State Work,Done Well Destruction Fj Well Diameter Sealing Material (top 501 i. Qepth .. Filer Materialblow 56'l TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION ( I. DESTRUCTION 1-1 (No septic system permitted i1 public sewer is available within 200 feet.) r �-=�--Installation-will serve-Residence "� Commercial-_-�J- Other - r Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: #__ � 1 Water table depth -SEPTIC TANK ❑ Type/Mfg tt Capacity A No. Compartments PKG. TREATMENT PLT. ❑ f: ( s Method of Disposal Distance to nearest: Well Foundation Property Line Iy Total length/size LEACHING LINE 1 0 No. & Length of lines 4 , FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS a I I Depth Siie t Number SUMPS ❑ Distance to nearest: Well Foundation Property Line i -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 an 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, l 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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant m st call 1 all req u a nspections. Complete drawing o reverse side. g Si ned X e: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date ��2' // �jj9— Area Q� �J Pit or Grout inspection by Date Final Inspection by�'M� "�Q _ Date�:� �'�`�°'Q b JF Additional Comments: l ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca {823-7104 ❑ Tracy 835-6385 f Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i a FEE AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. INFO + EH 1324(REV.i i N 5) r EH 14-26 4