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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT t 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (2091 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. V � City Lot Size PM Job Address i Address Phone Owner's Name i Contractor R.�� . Address License No. Phone k TYPE OF WELL/PUMP: # NEW WELL ❑ WELL REPLACEMENT ❑Ae DESTRUCTIO •^^-- "'� "" - 09 PUMP INSTALLATION-0— -SYSTEM REP OTHER (1 t ~,DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. IPROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL j PITS/SUMPS j INTENDED_ USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ll Industrial ❑ Open Bottom 11Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/I'rivat ❑ Gravel Pack '❑ Tracy Type of Casing Specifications 1-1 Public Ll Other ❑ Delta Depth of Grout Seal Type of Grout - I Irrigation ---- PP p A roz. De th i I Eastern Surface Seal Installed by - i Repair Work Done ❑ Type of Pump H.P. State Work Don Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') -- ` i TYPE OF SEPTIC WORK: NEW INSTALLATION l REPAIR/ADDITION l I DESTRUCTION l (No septiexsystem permitted if public sewer is (f\ �^^^^ —avaiiable-wrthrn 200 feet.) Installation will serve: Residence-/Commercial_ Other iP Number of living units: _JL_ Number of bedrooms _ r r k Character of soil to a depth of 3 feet: 3 Water table depth P. SEPTIC TANK [ thType/Mfg �� Capacity t � �No. Compartments PKG. TREATMENT PLT. ❑ j Method of Disposal I Distance to nearest: Well 1X150 Foundation S e..roperty Line LEACHING LINE 0--No. & Length of lines _Q��U Total length/size l FILTER BED 1-1Distancefo nearest Well Foundation '" 'Property Line SEEPAGE PITS 1.1 Depth Size Number !'1 .t F SUMPS LI Distance to nearest: Well Foundation `^ Property-Line DISPOSAL PONDS ❑ M1 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 DiWict. 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 Calif otnia."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 applimust 1 all required inspections. Complete drawing reverse side. Si ned XV � Title: [ 1 .18 Data: ` �} 9 FOR DEPARTMENT USE ONLY Application Accepted by Date —16 7— Area 1 Pit or Grout Inspection by Date Final Inspection by Date--7--7— Additional ate Zt I Additional Comments: ❑ Stk 4611-6781 ❑ Lodi 369-3621-4 1A Manteca-623-7104-- ❑=Tracy-835=6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 �� f * FEE � � INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY �DATE PERMITND. 13-24 IREV. i e 51 EH*14-28