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a �ri a APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address City 0_;&,e:�2xxof Size- T " PM Owner's Named Address Phone ContractorT/r Address w %�1 101U License No. frane �c TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT L7 DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FED. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i I� INTENDED_ USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS N ❑ industrial El Open Bottom Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1-1 Public M Other L1 Delta Depth of Grout Seal Type of Grout------:--. 11 Irrigation —.Approx. Depth I 1 Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter :Sealing-Material,Itop 5t}') Depth # Filler Material iBelow 50'1 TYPE OF SEPTIC WORK:' NEW INSTALLATION (I REPAIR/ADDITION l I DESTRUCTION (No septic system permitted if public sewer is , C available within 200 feet.) Installation will serve:: esidence_`- Commercial_ Other Number of living units: Number of bedrooms _ Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK �❑' Type/Mfg Capacity No. Compartments i PKG. TREATMENT PLT:,CI Method of Disposal r a• Distance to nearest: Well Foundation Property Line -� LEACHING LINE '❑ No. & Length of lines Total length/size - FILTER BED L7 Distance to nearest: Well Foundation Property Line it F SEEPAGE PITS I i Depth Uize Number f .+ar=s.r,o-un -� ,+.° SUMPS ❑ Distance to nearest: Well Foundation Property Lin6 DISPOSAL PONDS ❑ - hereby certify that t 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 ce"r"tities the'folkowing:"I certify that In the performance of the work foP 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 applicant must call for II r quinsvcti00. Complete drawing on reverse side. y Signed X Title: - �7r�`1 . Date: � ✓ FOR DEPARTMENT USE ONLY � k Application Accepted by . Date '^L c Ara, Pit or Grout Inspection ,Date Final Inspection by Date "�U7, Additional Comments: ✓ V L7 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Reium all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 s � + FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. ; + EH 13-24(A EV.riH51 EH 1426 1