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APPLICATION FOR PERMIT by42 r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application is fieteby 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 fo+r_sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. fr�J a City Lot Size PM Job Address r' I � ` Phone r I Owner's Name r Address ndf � = Contractor. ddress fr License No, Phone�7� TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION D SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES' DISPOSAL FLO, POOP. LINE �7 " FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREAOC NSTRUCTION SPECIFICATIONS O Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing I ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing T Specifications l'7 Public n Other CI Delta Depth of Grout Seal Type of Grout k v I I Irrigation ox. Depth I ! Eastern Surface Seal Installed by ; r _ r Repair Work Done El Type of Pump H.P. State Work Done — V, ' Well Destruction ❑ Well Diameter Sealing Material Itop 501. ,k, Depth Filler Material iBelow 501 -- r TYPE OF SEPTIC WORK: NEW INSTALLATION I I `REPAIR/ADDITION I I DESTRUCTava ION I I septic system permitted if public sewer is 5 available within 200 feet). Installation will serve: Residence__x Commercial _ Other Number of living units: __/- Number of bedrooms .7 f t i Water table depth Character of soil to a depth of 3 feet: SEPTIC TANK CYC- Type/Mfg ' Capacity �fl No. Compartments �— Method of Disposal PKG. TREATMENT PLT. ❑ Distance to nearest: Well 7 y 0 Foundation Property Line_.-V LEACHING LINE . _ ._15t,_No. & Length of lines 3 Total length/size FILTER BED ❑ Distance to nearest: Well /T!a Foundation Property Line SEEPAGE PITS l 1 Depth .24 Size .... Number SUMPS D Distance to nearest: Well .1�—O-.— Foundation Property Line DISPOSAL 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 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." Theapplicant t call for Ire ser!-irtSP-bear..Complete drawing on reverse side. Signed Title: Date: rt FOR DEPARTMENT USE ONLY Y —� Area f Application Accepted by Date — f or Grout Inspect by Date��Final Inspection Data Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 Cl Tracy 835-6385 r Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O_ Box 2009, Stk.,_CA 95201 FEE AMOUNT DUE AMOUNT REMITTED C K H RECEIVED BY DATE PERMIT NO. INFO r.EH13-241REV.1/k51 EH 14-26. �••.�