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10:0a i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT :Y { 1601 E. HAZEL T ON AVE., STOCKTON, CA I Telephone (209) 466-6781 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 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 Local Health District. 7-f� a�D��l � /y .J{ Lot Size PM Job Address . City Owner's Name �/ / kw" Address �� _ Phone Contractor�'/ �%3�_S„O.n Address L-W License No. 9 ) Phone / _.3:Z TYPE OF WELL/PUMP: NEW'WELLX WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER 0 /,r DISTANCE TO NEAREST: SEPTIC TANK f SEWER LINES �� DISPOSAL FLD. --' PROP. LINE / r FOUNDATION _- ._. AGRICULTURE WELL-----' OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1� ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation r` /� Dia. of Well Casing ,Vbomestic/Private Gravel Pack ❑ Tracy Type of Casing_ » — Specifications f ❑ Public ❑ Other ❑ Delta Depth of Grout Seal A10 _�� Type}of Grout �%j/ . I I irrigation '7--I?Approx. Depth I i Eastern Surface Seal Installed by 'Jcl �:� .� c _ Repair Work Done ❑ Type of Pump H.P. , State Work Done— I Well Destruction 'i ❑>_ Well Diameter Sealing 'Material Itop 501 J k Depth Y Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 1.1 DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.), Installation will serve: Residence_ Commercial_ Other Number of living units: 'Number of bedrooms o Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity - No. Compartments PKG. TREATMENT PLT. ❑ -p w Method of Disposal Distance to nearest: Well Foundation Property Line ' LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well '' Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared-,this application and that the work will he done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin ILocal Health District. i 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 ._certifies the following: "I certify that in the.performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws of California." 4 The applicant8il equired 1 Ps. Complete drawing on reverse side. Signed X_ Title: Date: . F i ?. F0 EPARTMENT USE ONLY t Application Accepted by Date Area - Pit or Grout Inspection b; I Ic - Date Final Inspection by Date Additional Comments:, 0 Stk 466-6781 ❑ Lodi 369-3621, ❑ Manteca 823-7104 ❑ Tracy 835-6385 tAppiicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 }, r INEO AMOUNT DUE AMOUNT REMITTED C k RECEIVED BY DATE PERMIT_N6. _ EH13-241REV.IIA51 , - EH 14-26