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i 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 r ICornplete 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. s Job Address � l/ � � �� "`-- "� - City Lot Size PM Owner's Name r Addressr! _ Phone,76 e2ZContractor `` t ess- `� nse N,. Phone / TYPE OF WELL/ U P: NEW W ❑ WELL REPLACEMENT 77 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 OFlWELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I ❑ Industrial - ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing i EJ Domestic lPrivate ❑-Gravel Pack ❑ Tracy Type of Casing Specifications 1-1 Public f7 Other Cl Delta Depth of Grout Seal Type of Grout. I I Irrigation -Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done El Type of Pump H.P~� W State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') s Depth Filler Material Melo 5D') O TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIRIADDITION DESTRUCTION I I (No septic system permitted if public sewer is 1 available within 200 feet.) installation will serve: Res' ence f Commercial— Other ; "9 Number of living units: Number of bedrooms gg Character of soil to a depth of 3 feet: i Water table depth SEPTIC TANK d 11 ' Type/Mfg _ Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property.Line r LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth A I%a ��Nuu7mper l �POSAL Ll Distance to nearest: Well Foundation L� Property Line J i 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, ando 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." 'i The applican t r all uir d i s ctions. C to drawing on reverse side. - l Signed Title: Date: FOR DEPARTMENT USE ONLY / Application Accepted by LDate 1 Q Area Pit or Grout Inspection by Date Final Inspection by Date t 3 U Additional Comments: ❑ Stk 466-6761 ❑ 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 i FEE INFO AMOUNT DUE AMOUNT RE ED ASH RECEIVED BY DATE PERMIT'NO. � d p +.EH 13-24 IREv.r/K51 70 f ]- L-3 -/20 0 1&qEH 14-28 - N�.