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I APPLICATION FOR PERMIT g A* k SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON'AVE., STOCKTON, CA k Telephone (209) 466-67$1 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.Tills application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for weft/pump and the Rules and Regulations of the San Joaquin Local Health District.,' <. R S r i Lot Size PM Job AddressC - t f t_ Phone Y _ T Owner's Name., Address Phos Contracto Address ;cense No TYPE OF ELL/PUMP: NEW WELL L1WELL REPLACEMEN ❑ DESTRUCTION LJF PUMP INSTALLATION ❑ �a SYSTEM REPAIR ❑ OTHER ❑ � DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLUT� 'PROP. LINE �f t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE* V,'TY,PE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS; T {" El Industrial ❑ Open Bottom_ 'j:❑ Manteca Dia. of Well ExcavationDia:of Well Casing - ❑ Domestic/Private ❑ Gravel Pack ❑•Tracy+s!..� Type o Casing " b Specifications r – f El Public ❑ Other ° ❑ DeltaDepth of Grout Seal Type of Grout fx , ❑ Irrigation ---Approz. Depth""'_❑ EasternSurface�,Seal stalled by ' Repair Work Done [I Type of Pump K. State Work Done 4 Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 50') ' TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION El DESTRUCTION C1 (No septic system permitted if public sewer is ` available within 200 feet./ Installation will serve: Resencs Commercial— Other ° Number of living units: Number of be ooms Character of soil to a depth of 3 feet: Water table depth i � T a/Mf —Capacity/,-)-- "'No:'Coiripartments" =SEPTIC TANK YP 9"""' "'"� s Method of Disposal i PKG. TREATMENT PLT. ❑ ` Distance to nearest: Well Foundation. Property Line LEACHING LINE ❑ No. & Length of lines _. Total length/size FILTER SED ❑ Distance to nearest: Well Foundation Property Linr l/� � �q � � � i e t l SEEPAGE PITS Cl Depth Size—r 3 — Number SUMPS ❑ Distance to nearest: Well. Foundation Property Line DISPOSAL PONDS PONDS ❑ 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 Califomia."Contractor's hiring or sub-contracting signature certifies the fallowing:"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 Califo Theapplican ust ca for all requi d i pec' plate drawing on arse ' F Title: Date: Signed O PARTMENT USE ONLY Date Area L Application Accepted by - Opt . Grout Inspection by Date �`� Final Inspection by Date Additional Comments: ❑ Stk 466-6781 CD Lodi 369-3621 E3 Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT N0. a + EK 13-241REV.i/ash EH 14-25 _..