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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. 549 for sewage-or No. 1862 for well/pump and the Rules d Regulations of the San Joaquin Local Health District. Job Address 8� 7 h� City )ST _* /L Lot Size _ PM eelk or-14,14X, ' Owner's Name Address G4ME— Phone Contractor ddress s- Uc �C ense No.;1212� Phon TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACE-MENT547 DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR"❑ '/O�TTH-EERR LJ DISTANCE TO NEAREST: SEPTIC TANK L,.— SEWER LINES T� DISPOSAL FLD.L6Z5 FROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL —~ PITS/SUMPS L INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca' • �Dia. of Well Excavation Dia. of Well Casing Domestic/Private 'Gravel Pack ❑ Tracy s Type of Casing1,7 VC Specifications ('1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout N7�� I I Irrigation. =.Approx• Depth - astern Surface Seal Installed by - i Repair Work Done ❑ Type of Pump /r H.P. State Work Done Well Destruction ❑ Well Diameter`` Sealing Material Stop 501 ft Depth f Filler Material (Below 501 — IVAU f TYPE OF SEPTIC WORK: NEW/INSTALLATION I 1 REPAIRIADDITION f I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet./ Installation will serve::. Residence_ Commercial_ Other Number of living units: Number of bedrooms *- Water table depth Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line i LEACHING LINE ❑ No.`& Length of lines Y Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I l Depth Size _ Number SUMPS L7 Distance to nearest: Well Foundation Property tine kDISPOSAL PONDS ❑ 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 f 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-conttacting 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 applic s 11 or all quire J pections. Complete drawing on/OVrse side. Signed X Title Date: ' FOR DEPARTMENT USE ONLY . Application Accepted by Date_ Area Pit or Grout nspection by Date` Final Inspection by Date Additional Comments: :2^�— �� `J ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Tj Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ® ravr CK#. O' eAMOUNT E DUE AMOUn ASH RECEIVED BY DATE PERMIT NO. INFO t EH 13-241REV.5iH 51 17 11 �C3i ^fib EH 14-28