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APPLICATION FOR PERMIT u o d SAN JOAdLIIN LOCAL HEALTH DISTRICT -y- 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 46G-6 91— T,3-*'L0 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. Job Address 1;?F1141 City of Size PM Owner's Name Address goo / r Phone Contractor S Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT © DESTRUCTION PUMP INSTALLATION 171 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 ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1-1 Public Cl Other Ll Delta Depth of Grout Seal Type of Grout I I Irrigation _-.Approx' Depth 1.1 Eastern Surface Seal Installed by _ Repair Work Done Ll Type of Pump T H.P. State Work un`- Well Destruction U. Well Diameter Sealing Material (top 50 14 Well y�+pCgy - Depth O Filler Material (Below 50') t` ; OC1 TYPE OF SEPTIC WORK: NEW INSTALLATIO 1 ] REPAIR/ADDITION l ] DESTRUC,IOiv t T-R septic syst ,permitted—4public sewer is—' available within 200 feet.I r' . Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK El Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation r _ Property Line LEACHING LINE U No. & Length of lines I I Total length/size T4 FILTER BED 7 ❑ Distance to nearest: Well Foundation Property Line J' SEEPAGE PITS`. i2r I I Depth .1 Size —� Number 1 SUMPS D Distance l nearest: r ,� Well Foundation Property Line DISPOSAL PONDS ❑ `I hereby certify that I have prepared this application Land that 4he work will be done A accordance with San Joaquin county ordinances, state laws, and rules and regulations of the,.San Joaquin Local Health/bRtrict. E Home owner`or licensed agent's signature certifies the following: "I certify that in"theiperformance of the work for which this permit is issued, I shall not employ any person inAuch manner as to become subject to workman's combensair6n aws of California." Contractor's hiring or sub-contracting signature certifies the following:9',-'J ertify that in the performance orihb work for which this perrt'lt is issued,I shall employ persons subject to workman's compensa- tionlaws of California".„ -- � _ ----- _- -- ---- — e ' The applicant to all req Md ons. Con�fete�II�a+Nitig'on ev side. - r Signed le: Date: , a "^ 'l; AIN ®(��y FOR DEPARTMENT USE ALY rte;-.!1 q Application Accepted by bate `-t� ' `Area , r ` 4L0 Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 Q Lodi 369-3621 ❑ Manteca 823-7104 0 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY /DATE // PERMIT`NO. *.EH 13-24(REV.1/9 51 EH t4- �I��f G _14-Mo