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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED n zbctll (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 Ryles and Regulations of the San Joaquin Local Health District. Job Address .' City C1A127 Lot Size "` �" PM Owner's NameE� AddressPhone 6VS r Contract ij� A Address �J E- ;cense Na. Phone 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 1 TYPE 6F_'WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ll Industrial r "❑_Open Bottom ❑ Manteca Dia. of Well Excavation $r 'Dia of Well Casing lF} 1:1Dornestic/Privat. e0El Gravel Pack` i ' ❑ Tracy Type of Casing T Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ ---Approx.r Approx. Depth *❑ Eastern Surface Seal Installed by Repair Work Dane ❑ Type of,PumA H.P.- _ `State Work Done Well Destruction ❑ .Well Diarileter t Sealing fVlatenal Itop 5a'i- �_— Depth Filler Matenal`IBelow>50'}'E `'' TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ `DESTRUCTION ❑ (No septic system permitted if public sewer is -:- -- - I available within 200 feet.) Installation will serve: Residence_i Commercial_ Other Number of living units:'�� t Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK -X Type/Mfg z Capacity No. Compartments PKG. TREATMENT PLT. ❑ t +�, '' Method of Disposal Distance to nearest: Well Foundation Property Line. 5904 - 1 LEACHING LINENo.'&-L-ength of lines Total length/size Q FILTER BED ,;; sDistance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth a Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ► 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. 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 follow, . certify t in the pe29s. nce of the work for which this permit is issued, I shall employ persons subject to workman's compensa- 1 tion laws of Cal' rnia." i` The applicant ust call all uir n Complete drawing on r v rse side. s Signed' Title: Date: � Td j OR RTMENT USE ONL Application Acc ted b l/ pp Y Date Area Pit or Grout Inspection by Date �jf-- Final'lnspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 17 Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 .. ti FEE CK INFO AMOUNT DUE ' AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. + EH 13-24 IRB'.1/851 EH 14-26 ♦ 'O J ' �1 A '��'� _