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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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.,�¢,9 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. JVJI 1.07 C Job Address ✓L City �� Lot Size PM_ . Owner's Name dyN. �R.k of Address sPhone. Contractor's Name icense No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION PUMP INSTALLA ION ❑ SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK ,06 _ SEWER LINES 1�J0.��f- 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 Domestic/Private KGravel Pack ❑ Tracy Type of Casing B Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout,Seal 5_0 Type of Grout ❑ Irrigation DZW___�Approx. Depth ❑ Eastern _ Surface Seal Installed by Z) Repair Work Done Type of Pump . H.P.__ / State Work Done Well Destruction Well Diamet r Sealing Material (top 5.0') A&4P Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is -J -. -, available within 200 feet.I Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a det)th of 3 feet: - h Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments r PKG. TREATMENT PLT. ❑ Method of Disposal �( Distance to nearest: Well Foundation Property Line �f LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ 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 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 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 appli call for all re ired i pections. omplete drawing on reverse side. 9 IFC. Signed c Title: � Date: p r G�L3 5 S �+r� �� FOR DEPARTMENT USE ONLY Application Accepted by Area Date ✓/Z 4e Z__ Pit Grout l spection by Date Final Inspection by Date S Additional Comments: Vtk 466-6781 C3 Lodi 360-3621 ❑ Manteca 823-7104 El Tracy 835-6385 V" scant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIY'NO. INFO CASH + EH 1324(REV,10/631 b�Z gb `IiQ�L EH 7426