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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. H_AZELT 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.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Jab Address Gr City - � Lot Size PM7 100 J'I'i�nt r '!'t Address J > � �yY1 s--'� rhone Owner's Name r —�.�--_...,.—•.—.�•�-- [� vN1 l .^�d"C' i/ ��1'+� icense No. Phone rtontractor's Name ^� F TYPE_'OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT-#❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR 1-11 OTHER El DISTANCE TO NEAREST: SEPTIC TANK J2 .1 SEWER-LINES""'"'"" 'DISPOSAL FL'D. f-* PROF. LINE FOUNDATION i AGRICULTURE WELL# ''''OTHER WELL13—D2�---f PITS/SUMPS/—" Cl, �t- INTENDED USE TYPE OF WELL PROBLEM ARTA CONSTRUCTION SPECIFICATIONS .0, . ❑ Industrial ❑ Open Bottom ❑ Manteca Dia"of Well Excavation ' ;,Did of Well Casing Domestic/Private El Gravel Pack ❑ Tracy .Type of Casing f Specifications ^�" Type of Grout ❑ Public ❑ Other ❑ Delta Depth of Grout Seal *0 ! rface Seal Installed by LJIrrigation --Approx. Depth ElEasterrflW Su Repair Work Done [3Type of Pump i"� -- H.P. State Work Done } D(1 Well Destruction El Well Diameter Sealing Material (top 50') DepthFiller Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION C]—REPAIR/ADDITION ❑—DESTRUCTION ❑`(Noseptic system m emitted if public sewer is eet k Installation will serve: Residence__I Commercial_ Other til f Number of living units: Number of bedrooms F Character of soil to a depth of 3 feet:? Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments I + PKG. TREATMENT PLT. ❑ Method of Disposal i Distance to nearest: Well Foundation Property Line � I LEACHING LINE 11No. & Length of lines Total lengthlsize FILTER BED ❑ Distance to nearest: Well Foundation Property Line I SEEPAGE PITS ❑ Depth T Size Number ' SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 I 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." „ k The applicant must call fo il r it inspa n Compiete drawing on reverse side. Signed Title: > "` Date: r - FOR DEPARTM T USE ONLY t 001, _2 Application Accepted by o `- Date '� Area Pit or Grout Inspection by Date �� r.i- Final Inspection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy; 835— Applicant- Return all copies to: Environmental Health Permit/Services 1601 E: Hazelton Aver P.O. Box 2009, Stk., CA 95201 I FEE AMOUNT DUE AMOUNT REMITTED C.AgH RECEIVER BY DATE PERMIT N0. i + EH 13-24(REV.10193) INFO r_ y EH 1426 __