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r APPLICATION.FOR PERMIT SAN JOAQUIN LOCAL,HEALTH DISTRICT ` 1601 E. HAZETON AVE.,:STOCKTON, CA (�D Telephone (209) 466-6781 ( PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I {:�,:.•t�; Y; ,,�. w (Complete in Triplicate) k Application is thereby 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 I Local Health District:.!". { Job Address -1 Ste ' * I✓l�•" A 1 VTy 'Al'ck'�0401 Size Cit PM ' Owners Name J �'�Q I 0 up'e .f. 4��ddress' ' c Q ��{ I �5��C �U(` n' �_. V- Phone Contractor `-' Address License No. Phone TYPE OF WELL/PUMP: NEW WELL F3 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE N ! FOUNDATION'- AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS E ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing t ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ----Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC.WORK: NEW INSTALLATION ❑ REPAIR/ADDITION 0 DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial T Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: f " Water table depth SEPTIC TANK Type/Mfg Capacity V No, �Compartments _ _ PKG. TREATMENT PLT. Cil Method of Disposal Distance to nearest: Well Foundation Property Line t t LEACHING LINE ❑ No: & Length of lines Total length/size FILTER BED -❑ Distance to nearest: Well Foundation Property Line !. SEEPAGE PITS 171' Depth Size Number SUMPS ❑- Distance to nearest: Well Foundation Property Line ' k s DISPOSAL PONDS ❑ € I hereby certify that I have prepared this applicationand 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. I L { Home owner or licensed agent's signature certifies the fallowing: "I certify6that in the performance of the work for which this permit is issued,I shall not employ any person in such manner as to become Isubject 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." a,i'1 1 . j The applicant mus call for all required inactions. Complete drawing on reverse side. [��J( ft. w"w. Signed Title, Date: FOR DEPARTMENT USE ONLY r Application Accepted by Date Area �r l Pit or Grout Inspection Date \ Final Inspection by Dat `1 v� c _ • Additional Comments: ❑ Stk 466-6781 ❑ Lodi. -3621 ❑ Manteca 7104 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 4 FEE INFO AAMOOUUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMI7'NO. EH 13-141REV.I/ii 57 .`4� r.vC "i �r•� A ` 1