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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 •: '.� IComplete 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 � City ..Lot Size�� ylly w PM L 10-uwteftj Owner Name Address t��f Phone 7 00v Contractor's Name License No. Ora of Phone TYPE OF WELL/PUMP: NEW WE L ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION`JC SYSTEM REPAIR F 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 El Manteca Dia. Of Well Excavation Dia. of Wel! Casing O ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications W Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation0� _.-Z—Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done' 4] Type of Pump t&t&".1 H.P.=a?S' " "'""""a _ State Work Don Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') s p i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑—DESTRUCTION ❑ (No septic system permitted if public sewer is i' I I I 4CO available within 200 feet.) Installation will serve: Residence— Commercial— Other. Number of living units: Number of bedrooms to o-.. ... b Character of soil to a depth of 3 feet: s ;^ = Water table depth SEPTIC TANK ❑ T e/Mf YP 9 � _ Capacity No. Compartments PKG. TREATMENT PLT. ❑ I Method of Disposal Distance to nearest: Well Foundation Property Line ,m LEACHING LINE ❑ No. & Length of lines "� " ' ' Total length/size � FILTER BED ❑ Distance to nearest: Well { Foundation Property Line SEEPAGE PITS 6 ❑ Depth" Size ' Number---" Z SUMPS ❑ Distance to nearest: Well Foundation -Property Line DISPOSAL 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 Z) rules and regulations of the San Joaquin Local Health District. 0 ;U 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 i employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting 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 applicant must call f ala required inspections. Complete drawing on reverse side. Signed Title: _ Date: FOR DEPARTMENT USE ONLY { Application Accepted by Date AreaL� 4 Pit or Grout Inspection by Date Final Inspection by pate Additional Comments: ❑ Stk 466-6781 ❑ Lodi 389-3621 ❑ 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 CK i INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. +EH13.24IREV.10l931 � �LrN � Z-II� per,/U7. EH 1429 f-'� 0Q