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I APPLICATION FOR PERMIT w1 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 i 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 o(. o. IB62 for weOpump and the Rules and Regulations of the San Joaquin Local Health District. r c Job Address De, City ! "D tot Size �r PM Owner's Name f ji� r QAddress � Phone Contracto Address t 1) Lo plSP h3on�e� pLicense No. ; TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF,WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ,1 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F] Public n Other t ❑ Delta Deptti of Grout Seal T �... Type of Grout I 1 Irrigation -Approx. Depth I 1 Eastern Surface Seal Installed by - lz Repair Work Done ❑ # Type of Pump H.P. State Work Done k Well Destruction ❑ Well Diameter Sealing Material {top 50'1 t Depth Filler Material (Be)ow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i DESTRUCTION l I (No septic system permitted if public sewer is llf available within 200 ieet.l .� Installation will serve: Residence JEI�— Commercial— Other Number of living units: Number of bedrooms F , Character of soil to a d pth of 3 feet: I Water_table depth i SEPTIC TANK. 1� Type/Mfg CCapacity�`LQ� No. Compartments PKG. TREATMENT PLT`❑ / I Method of Disposal Distance to nearest:-— Well Foundation *Property-Line� a LEACHING UNE ❑ No. & Length of lines Total length/size i FILTER BED ❑ Distance to nearest: Well Foundation Property.Line .n. ;- 1. IM \ SEEPAGE PITSj I 1 Dept i Size Number s SUMPS ' Distanc`,e 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 taws, an� rules and regulations of the San Joaquin Local Health District. 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 ift,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 mustjcall for d inspections. Complete drawing on reverse side.Signed X �Title: L ✓e- t/ Date: 61It FOR DEPARTMENT USE ONLY r Application Accepted by / i//,/4�� - Date r Area Pit or Grout Inspection by I� date Final Inspection by Date ' Additional Comments: !I!I ❑ Stk 466-6781 ❑ Lodi 3691-3621 ❑ 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 f I� k - INFO FEE AMOUNT DUE +AMOUNT REMITTED CASH CK RECEIVED BY DATE(` (�PERMIT-NO. t EH 13.24(REV.F i n d I7d • 610 C-//T � �r v T U.� • // - . EH 1428 / JJJ` . /// ,