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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR 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. b Job Address City Lot Size S PM Owner's Name Address 1 Phone` d f �^ Contractor rens l T License No. iTV? Phone-7 t 'TYPE-OF-WEL"L'1PUMP:"" . _- "—NEW'WEL-h❑�WEL-L REPLACEMENT ❑ ,DESTRUCTION,❑ I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ,., DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE z FOUNDATION AGRICULTURE WELL OTHER WELL _ -.- _,PITS/SUMPS Y INTENDED USE i TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS s ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation r Dia. of Well Casing � ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing - _-� Specifications M Public ❑ Other ❑ Delta Depth of Grout Seat ' Type-of-Grout `r I I Irrigation _Approx. Depth I I Eastern Surface Seat Installed by n ? - �" Re air Work Done ❑ Type of Pump H.P. StateMbrk.-Done } ' p Y= Well Destruction ❑ Well Diameter Sealing Material {top 501 �L Depth Filler Material (Below 50') F 05 � I TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRIADDITION l I DESTRUCTION i I (No septic system permitted if public sewer is available within 200 feet-ice ,. I 'Installation will serve:: Residence _ Commercial Other ` r 'Number of living units: `. Number of bedrooms y 4 . .�Character of soil to a depth of 3 feet:Wgn ater table depth SEPTIC TANK ElType/Mfg Capacity 2U No. Compartments' P,KG. TREATMENT PLT- ❑ F, !+ Method of Disno al ? *� ell Distance�to_nearest: � Well Foundation ! � Property Line %�O, { t �= f LEACHING LINE ❑ No. & Length of linesk4fTotal length/size ' FIILTER SED ❑ Distanceell_to nearest: WFoundation _7 - Property Line 4 - r -72 SEEPAGE PITS 11 Depth Size Number '3 ' SUMPS ❑ Distance to nearest: Well I=M Foundation/t��— Property Line �r 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 < e -lutes and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performar6.oPttie.work for which this permit is issued, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contr'actor'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-i Y tion laws of California." The applicant ust call for II require inspections. Complete drawing on reverse side. 4 >F r h r 2=16 Signed X Tiile: � Date: 2� 11( FOR,1PEPARTMENT USE.ONLY - 7_7�� r Application Accepted by r Date Area f �7 Pit or Grout Inspection by Dates '+_ Final Inspection byDate Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 t FEE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY- DAT '� / PERMIT'NO. INFO _ },�.,_..�..�.�...,. ��... � - + EH 13-I41REV.1/A5r V V I f �� •�ZS 1., _ EH 14-26