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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT a. 1601 E. HAZE T ON AVE., STOCKTON, CA " Telephone (209) 466-6181 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) F 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 r 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. � t� X77— Job Address � ,� City s Lot Size / 19PM Owner's Name ef Address Phone ;3 r Contractor Address License Nb. F Phone r TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: NK SEWER-LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM ARE STRUCTION SPECIFICATIONS ClIndustrial ❑ Open Bottom ClManteca Dia. of Well Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F"7 Public 0 Other ❑ Delta Depth of Grout Seal Typ out 11 Irrigation. —.Approx. Depth •1 1 Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑• Well Diameter Sealing Material (top 50') Depth _ Filler Material (Below 50'1 — TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION XMo septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_, Other P 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 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property.Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line /f SEEPAGE PITS 11 Depth Size ot Number SUMPS L 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 Diltrict. ` 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 r 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 call for all required inspections. Complete drawing`on reverse side, Ci L" l., Signed XTitle: Date: 1 F a FOR DEPARTMENT USE. ONLY Q Application Accepted by Date 2 Area Pit or Grout Inspection by Dalt �Ilnsp�ecaion by Date i Additional Comments: �� f ❑ Stk 466-6781 ❑ Lodi 369-3621 - ❑ Manteca 823-7104 ❑ Tracy 635-6385, 2009, Stk., CA 95201 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box f yF FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT'NO. l O CASH /!t r +_EH 13.24(FEY.s/xW INF1 Q 7'�Y �/'��>� rra—,T . EH 14-26 O