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APPLICATION-FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES I YEAR FROM DATE ISSUED l _ (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 Q City O ,t%� lot-gize A PM Owner's Name y ✓ Add , ress c� t Phone { Contractor's Name G License No. _ �J Phone TYPE OF WELL/PUMP: IMS NEW-WELL WELL REPLACEMENT DESTRUCTION YL1 PUMP 7NSTALLATJIDN SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTI h TANK -lE, S SEWER LINES _ DISPOSAL FLD, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL -2,5'rPITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1� ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation :Dia. of Well Casing ?Womestic/Private Gravel Pack ❑ Tracy Y Type of Casing s ! #Specifications C7 Public ❑ Other 13 Delta Depth of Grout Seal Typ of rout 171 Irrigation p�o�O 'Approx. Depth ❑ Eastern Surface Seal Installed by 4C C4 Repair Work Done ❑ Type of Pump H.P. r State Work Don tt,nn Well DesAl go ELY tructioril' _ Well Dig meter Sealing Material (top*50') . J" Depth hr`90 Filler Material (Below 50') TYPE OF SERT..IC WORK: NEW INSTALLATION El REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is it I� available within 200 feet.) 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 SEPTIC TANK Ll Type/Mfg +Capacity No. Compartments PKG. TREATMENT PLT. ❑ �I d l Method of-Disposal Distance to nearest: Well Foundation Property Line i ^� LEACHING LINE ❑ ,No. & Length of lines ' Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line #V " SEEPAGE PITS ❑ Depth Number i I SUMPS ❑ Distance to nearest: well ¢ ." Foundation Property`Line DISPOSAL PONDS ❑ 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. t 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 thatrin the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California. II The applic s call for all required i ctions. omplete ing on raver side. j Signed D Title: s rf s -.. ate: FOR DEPARTMENT USE ONLY Application Accepted b � D 5.F Date y , Area Pit or Grout Inspection b ' ~ C " pe Y ti. Date � Final Inspection by pie Additional Comments: 6 ❑ Stk 466-6781 ❑ Lodi 364-3621 ❑ Manteca 823-7104 ❑ Tracy 835.6385 �-- Applicant=-Return"all"copies to Environmental Health"-Permit/Services 7601 E:Hazelton Ave.; P.-0.-Bo`x-2009;1-Stk:;_CA_95201 FEE - ` INFO AMOUNT DUE` i AMOUNT REMITTED` SCK# "�' RECEIVED BY DATE PERMIT"NO." CASH tt + EEH 13-24 H 1426 IREV.101031