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APPLICATION FOR PERMIT `WA SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA �� Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ,yV1R�?J, SR�lCa (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. Job AddressSeo � � , `� - City�� of Size PM Owner's Name --5 Address Phone _LL Contractor �^� Address .3 / d License No2Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ 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 OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 3 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public 171 Other w+ F1 Delta Depth of Grout Seal - �` -Type of Grout I I lrngation- —Approx. Depth t I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump 4116 H.P. I State Work Done Well Destruction ❑ Well Diameter ft Sealing Material /top 501 t Depth Filler Material.(.Below'50') TYPE OF SEPTIC WORK: NEW INSTALLATION 11 RFPAIWADDITION l 1 DESTRUCTION I i (No septic.sysiem permitted if public sewer is I available.within 200 4eet.) installation will serve: Residence Commercial_ Other - £ Number of living units: Number of bedrooms ` a Water table depth Character of soil to a depth of 3 feet: - '� p SEPTICv,TANK ❑ Type/Mfg ;Capacity - No. Compartments PKG-. TREATMENT PLT. ❑ i -. Method of Disposal Distance to nearest: Well Foundation Property Line � t � LEACHING LINE ❑ No. & Length of lines Total length/size FILTER,'BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size r - ' Number SUMPS tl Distance to nearest: Well Foundation Property Line DISPOSAL-PONDS ❑ Ft - r 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 certifieslthe 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 lavys of California." M t The applicant mus al o• I required in pections. Complete drawing on reverse side. . Signed f �w�. s Title-s%�/o��^�Qf �L _ _ Date:1511" 1� FOR DEPARTMENT USE ONLY t Application Accepted by Date Area E I Pit or Grout Inspection by Date Final Inspection by Date t C I Additional Comments: ❑ Stk r 466-6781 ❑ 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 ! f j FEE f ' AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT N0. INFO /:)-7 El +.EH 13-24 I REV.i i a s! f I'i EO 14-211 I { r