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ri APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) f 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. Job Address C—�-A ice: City Lot Size PM s Owner's Na - Address Phone Contra `S�V Address 7-"!C) License No.3 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ r 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 �. reD❑ dustrial ❑ Open Bottom ❑ Manteca�' Dia. of Well Excavation Dia. of Well Casing k- C1omestic/Private ❑ Gfavel Pack - Tracy i -Type of Casing Specifications LLL1'1 Public ❑ Other ❑ Delta * ° Depth of Grout Seal Type of Grout _ I i Irrigation , _.Approx. DfMh l I Eastern Surface Seal installed by t } Repair Work Doner,l ❑� Typeof Pump H.F;. . State Work pon A! Wel; Destruction ❑ Well Diameter'J Sealing Material (top 501 Depths } Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION-11-6-REPAIR/ADDITION [ I DESTRUCTION i I (No septic system permitted if public sewer is t au i available within 200 feet.) Installation will serve: Residence_ Commercial_ Other (� , Number of living units: Number of bedrooms ? 0 G Character of soil to a depth of 3 feet: Water table depth i SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line . � F �' LEACHING LINE ❑ No. & Length of lines i 9 Total length/size FILTER BED ❑ Distance to nearest: Well_ Foundation Property Line Ir SEEPAGE PITS I I Depth Size Number SUMPS D Distance to nearest: Well Foundation Property Line i DISPOSAL PONDS ❑ g(� 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 tp rules and regulations of the San Joaquin Local Health District. r 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-contractirig signature certifies file (lowing: "I certify that in th :irlorma a of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws lifornia." The applit.ntustcalf r II re wired i s amplete drawing on r arse side. Si ned X `✓`� � Title: , _ Date: FOR DEPARTMENT USE ONLY Application Accepted by Date !J -2 �! Area i ' r Pit or Grout Inspection by r} Date Final Inspection by Date �� j Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 j Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED liY PATE PERMIT'NO. INFO CASH + EH 13-241REV. EH 1428