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4_1 4 . APPLICATION FOR PERMIT SAN JOAQUIN'LOCAL HEALTH DISTRICT 1601 E..HAZELTON AVE., STOCKTON, CA s Telephone (209) 466-6781 f PERMIT EXPIRES 1 YEARTROM 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. 1861 for well pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address b ✓ l�' City Lot Size c PM Owner's Name ;r��''j r—"I Address Phone. Contractor W It [ Address '7 / 41 U A k ' ,cense No. Phone '9 TYPE OF WELL/PUMP.* i NEW WELL_ 1 "% -"WELL'REPLACEMENT,'❑ DESTRUCTION ❑ t � l PUMP INSTALLATIO ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST- SEPTIC TANK ASEW_ER_LINES' "'� � DISPOSAL FLD.�_PROP. LINE -30 + FOUNDATION �� AGRICULTURE WELL ��- OTHER WELL r {PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM'AREA •CONSTRUCTION SPECIFICATIONS ❑ Industrial Open Bottom ❑ Manteca Dia:=of,Well Excavation �Dia:-Of Well Casing t� 76omestic/Private /❑ Gravel Pack El Tracy Type of Casing Specifications /0J ej f ❑ Public ILJ Other ❑ Delta Depth of Grout Seal SD f Ty of Grout i ❑ Irrigation —"'–_.A proz. Depth--E"Easter'n—SurFace`Seal-InstaNe`d by�" Repair Work Done ❑ ,Type of Pump H.P. State Work Done Well Destruction ❑ )Well Diameter Sealing Material (top 501 Depth Filler Material {Below 501 TYPE OF SEPTIC WORK:i NEW INSTALLATION ❑ REPAIR_/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_.._ Other l Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity "'—No-Compartments PKG. TREATMENT PLT. 0 ) Method of Disposal # Distance to nearest: Well Foundation Propert}Line " s LEACHING LINE El No. & Length of lines Len y P 9Total lerigth/size " FILTER BED ❑ Distance to nearest: Well Foundation s. Property Line } i SEEPAGE PITS 0 Depth Size p' - Number -' { SUMPS "" E73 'Distance'to nearest:- —Well Property Line- "Is, 1 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 4 rules and regulations"of-the San-Joaquin"LOcal-Heeltli District. _ 1 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 applicant mu al for all required inspection plate drawing on reverse side. ^� Signed itle: � Date: �� / / FOR DEPARTMENT USE ONLY S .5 R Application Accepted by Date Area Pit or.Grout Inspection by Date Q Final Inspection by Date M Additional Comments: S r �/vZ iS y ` ❑ Stk 466-6781 ❑ Lodi'369-3 Manteca 823-7104 ❑ Tracy 835-6385 , Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE CK* INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE + EH 13-24(REV.1/0'5) /C)OS�� EH I'm I V f T