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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 I PERMIT EXPIRES 1-YEAR 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. t ` Lot Size PM Job Address City r' Ownes Name 1 'Address 60`� WoJeA r Phone _ y � 93l- 5iQ2f Phone ContractorP___ O Address License No. _ - L. # TYPE OF WELL/PUMP: k NEW WELL WELL REPLACEMENT El DESTRUCTION 11i PUMP NEW CJ SYSTEM REPAIR ❑ OTHER ❑ " ' A DISPOSAL FLD. PROP. LINE 25) DISTANCE TO NEAREST: SEPTIC TANK r SEWER LINES': . .`FOUNDATION AGRICULTURE WELL"._ OTHER"WELL PITSISUMP.S- _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS rf ❑ Industrial Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing D Domestic/Private 11 Gravel Pack ❑ Tracy Type of Casing G Specifications 1 FI Public + = C3 Other ❑ Delta Depth of Grout Seal Type of Grout Il/Irrigation -=.Approx. Depth l 1 Eastern Surface Seal Installed by - Repair Work-Done ❑` Type of Pump H.P. State Work Done i WellDestruction ❑ Well Diameter Sealing Material (top 50'f Depth Filler Material (Below 50') -- TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIRIADDITION I 1 DESTRUCTION I 1 lNo septic system permitted Arewer,,,s,. available within 200 feet.) Installation will serve: Residence— Commercial_ Other f Number of living units':-n_--- -Number of bedrooms d. \J 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 {� t LEACHINGINE II-'-,Ur.No:& Length of lines Total length/size l V FILTER BED ❑ DiMance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size Number , �r SUMPS n Distance to nearest: Well - Foundation Property Line DISPOSAL PONDS ❑ , �'14le \ 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: "!certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa _ t tion laws of California.", , The applicant must call for all require inspections. Complete drawing on reverse side. y i Signed Title: ( Data: / 9 Ct FOR DEPARTMENT USE ONLY �f Application Accepted by` Date_( ✓�� Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: " , C1 Stk 466.6781 ❑ Lodi 369-3621 ❑ enteca 823-7104 C1Tracy 835-6365 �� Applicant- Return all copies to: Environmental Health Per 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 k ` o FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY GATE PERMIT'NO. INFO / 61 W_ly+�yvV^\ +.EH13-241REV. �iKsf EH 14-26