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w APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA i` Telephone (209) 466-6781 Zwt PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) rt D 2,- 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 I 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 City Lot Size PM Owner's Name � f �f^r.tJ Address 19\ J 6 Phone d1 Contractor Address xe;lLicense No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal E. Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H,P. ` State Work Done ` _ N � Well Destruction ❑ Well Diameter, ..�� Sealing Material {top 56'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is -e. t w E available within 200 feet.) Installation will serve: Residence Commercial_ Other Number oPliving units: --I— Number of be ooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg i Capacity Uv No. Compartments i PKG. TREATMENT PLT. ❑ # I � Method of /Dispos,zil Distance to nearest: Well FoundationProperty Line LEACHING LINE ,J ( No. & Length of lines �-- *y - ' _ Total length/size FILTER BED ❑ Distance to nearest--., Well 6LQ_� Foundation�_ Property Line SEEPAGE PITS ❑ Depth Size Number — SUMPS L7 Distance to nearest: Well ,�(U Foundation/60 Property Line l DISPOSAL PONDS ❑ I 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.- �I `�, i Home owner or licensed agent's signature certifies the following:Cl 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 r 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." f The applicant t cal r a I requir ctions. Com to drawing o erse side. ` � .rt Signed Titli Date: 7 t _ FOR DEPARTMENT USE ONLY Application Accepted by Date /--'23 kwo_ Area Pit or Grout Inspection by Date-27— "gFinal Inspection by Date7— Additional Comments:: - ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354M Applicant- Return all copies to: Environmental Health Permit/Servioes 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 s FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO + + EH 13-24(REV.1/a 5) EH 1428 !