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APPLICATIOWFOR 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) 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 _�;. �57r oew syDLL City Size .?&9 009 C r PM Owner's Name �[�d� /��f.a��( �A Address e2J7 ✓l G`� Phone Contractor Ld Address c7q!? —e k! v�L 'License No. C� Phone y TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑'. PUMP INSTALLATION If SYSTEM REPAIR-PIZ OTHER ❑ DISTANCE TO NEAREST: SEPTIC-TANK SEWER LINES - DISPOSAL FLf}. PROP. LINE FOUNDAT10Nh. - AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL `°"'--PROBL`EM AREA. CONSTRUCTION SPECIFICATIONS L-1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Wel! Excavation Dia. of Well Casing'. Domestic/Private ❑ Gravel Pack ❑ Tracy ` Type of Casing 5v7e 0,4_ Specifications � i'] Public ❑ Other fl Delta Depth of_Grout Seal lD0 ; Type of Grout t p —„ I I Irrigation a6e__Approx. Depth I I Eastern Surface Seal Installed by I / t P Repair Work Done � Type of Pump er H.P. State Work Donet� P Well Destruction © Well Diameter Sealing Material (top 50') Depth Filler Material l6elow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION LI DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) V i Installation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth n SEPTIC TANK Ll Type/Mfg �' Capacity No. Compartments 111 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line li SEEPAGE PITS i I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 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, 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 applic mus call for all requir nspec ns. C plate drawing on Signed XTitle: !:z�ide. e 5 Date: M F. DEPARTMENT USE ONLY Application Accepted by Date 'OIL--c Area k Pit or Grout Inspection by , Date ✓ Final Inspection by 15C, V Date— — ` Additional Comments: — Cl Stk 466-6781 ❑ Lodi+ 369-3621' ❑ Manteca 823-7104 r *❑ Tracy 1836-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i V.- FEE ! i INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE /yPERM17'JNO. ..EH 13-24 EK 1028(REV.$/H5) , 00