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f APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 i ' PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) I i 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 .i Local Health District. pAII City 4✓1�� Lot Size II PM Job Address pp '/�r�lt j Owner's Name Address _ Phone Contractor /5/g Address i5 ? � License No. Phone_ i TYPE OF WELL/PUMP: NW WELL WELL REPLACEMENT Q DESTRUCTION ❑� PUMP INSTALLATION X SYSTEM REPAIR ❑ OTHER ❑! t DISTANCE TO NEAREST: SEPTIC TANK _Zeg SEWER LINES �—"'—~ DISPOSAL FLD. PROP. LINE 7L- AGRICULTURE SO '� AGRICULTURE WELL — OTHER WELL r . PITS/SUMPS ZDd t INTENDED USE TYPE OF WELL , PROBLEM AREA CONSTRUCTION-SPECIFICATIONS- �-- " I` 11 El Industrial E) Open Bottom '`-[I Manteca Dia. of Well Excavation Dia.4of Well Casing ❑ Domestic/PrivateGravel Pack ❑ Tracy Type of Casing r SpecificationsIx �� l l Public �n Other `l lFU_elta ` Dept_ hof Grout Seal ! 0 Type of Grout - Irrigation 360 Approx. Depth I LEasi rR�;a Surface Seal-Instahed by f� { � Repair Work Done f❑ Type of Pump ';H I �d J 5- --Stat Work Done l \\y Well Destruction ❑ Well Diameter f Sealing Material_(top b0') f Depth i Filler Material,(Below ! TYPE OF SEPTIC WORK: NEW INSTALLATION iI'I 'REPAIR/ADDITION ! I DESTRUCT-ION I I'(No septic system permitted if public.sewer is avaijable.within 200'feet.) s r � I �y Installation will serve: Residence— Commercial Other Number of living units: Number of bedrooms `'"' 1 3 Character of soil to a depth of 3 feet: ' J f�"'�"�"`� , Water table d pth g SEPTIC TANK ❑ Type/Mfg '- - Capacity - yNo._Compartments ff . � Method of Disposal PKG. TREATMENT PLT. ❑ ` Distance to nearest: Well Foundation Property Line Ip I LEACHING LINE ❑ No. & Length of lines ` Total length/size ' o FILTER BED ❑ Distance to nearest: Well �� Foundations Property Line"— SEEPAGE ineSEEPAGE PITS I ) Depth Size "Number SUMPS ❑ Distance to nearest: Well Foundation tion `�-'+€ 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 col`my 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 pdrfo'rmance 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-,),shall employ persons subject to workman's compensa- tion laws of California." 11 The applicant5 c a fired ' o omplete drawing on rever side. Signed Title: Date: JV 2r� FOR DEPARTMENT USE 2LY ` — Application Accepted by Date r�G Area c� II Pit orrout I spection b Date -� 2_ ` inal Inspection by Date I� Additional Comments: 1.1Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-&385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY GATE , PERMIT"NO. +.EH 13.241REV.1/R5) INFO � d `bV rs EH 14.26