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I 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 . (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. a�k Job Address G City Lot Size 9� 'QPM Owner's Name "� r"�° Address"' Phone J sr .�. f Contractor d resA&'l—icense' No. Phone i r TYPE OF WELL/PUMP: !' NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK -SEWER LINES DISPOSAL FLD" PROP. LINE FOUNDATION '.AGRICULTURE WELL OTHER WELL PITS/SUMPS .1 D INTENDED USE TYPE OF WELL PROBLEM AREA -CONSTRUCTION SPECIFICATIONS -0 ❑ Industrial ❑ Open Bottom El-Manteca. V _- _Dia. of Well.Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public 17 Other fl Delta Depth of Grout Seal' Type of Grout _ . I I I Irrigation Depth 11 Eastern Surface Seal Installed by r Repair Work Done ❑ Type of Pump H,P. State Work Done t Well Destruction ❑ Well Diameter Sealing Material (top 501 r i Depth Filler Material Welow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIRIADDITION i I DESTRUCTION i' I (No septic system permitted if public sewer is r %% i available within 200 feet.) Installation will serve: Residence_ Commercial— Other r s f Number of living units: Number of ber oms /9— Character of soil to a depth of 3 feet: r Water table depth SEPTIC TANK ! LIType/Mfg ap i No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest, Well Foundation Property Line 46) to j LEACHING LINE'T""""""'❑{ "No. & Length of lin/es Total length/size e �` FILTER SED ❑ Distance to nearest: Well Foundation -s Property Line w SEEPAGE PITS I I Depth Size N bar " SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ + I hereby certify that I have prepared this application and that the woik 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 fallowing: "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 pertormance"of,the work for_which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." I ; The applicant ust call fJr ailoequired ins ctions. Complete drawing',on reverse side. Signed X Title: _-_ - - Date: �\ •/ I FOR DEPARTMENT USE ONLY % ` -3 /F ff Application Accepted by �/, L! G.•.1,� Date Area Pit or Grout Inspection by Date Final Inspection byD /�^��"�- ate �� ► C Additional Comments: ❑ Stk. 466-6781 -_,_—13 Lodi 369-3621 ,a. - ❑ Manteca,,823-7104,- ❑.Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 # CK IFEENFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. +.EH 13-241REV.i/R51 EH 14-28