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APPLICATION FOR PERMIT3i" SAN JOAQUIN LOCAL HEALTH DISTRICT , . g INV r ul 1601 E. HAZETON AVE., STOCKTON, CA Telephone 12091 466-6781 r PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ;l'r !Complete in Triplicate? !! O� RR~ �C�S Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the worfra� fticfec45fiis application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules an e�$uut ations of the San Joaquin Local Health District. Job Address City Lot Size PM Owner's Name 1"' Address �f_7- 1 �[I �i-ri1 !rx t w^f.�-Phone - Contractor Address q� 6 License N D Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT © DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR C' 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 I ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C+3'bomestic/Private -❑ Gravel Pack •❑ Tracy Type of Casing Specifications r-1 Public F1 Other 17 Delta Depth of Grout Seal Type of Grout —.-- I Irrigation _..Approx. D ti I I Eastern Surface Seal Installed by Repair WorkVDone C]' Type of Pump �L HP Repair State Work Done r Well Destruction ❑ Well Diameter Sealing Material-(top.50')- Depth Filler Material (Below 501 J TYPE OF SEPTIC WORK;- NEW INSTALLATION I1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.? Insta erne: Residence- erc Commial �Other----_ - Number of living units: umber of bedrooms ? --� Character of soil to a depth of 3 feet: r Water table depth SEPTIC TANK ❑ Type/Mfg f 'Capacity—L— No. Compartments PKG. TREATMENT PLT. ❑ # Method of Disposal Distance to nearest: Well Foundation Property line ' fr 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 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,1 shall employ persons subject to workman's compensa- tion laws of California." , I The applicant mV0 call fora req red inspect ns. Complete drawing on reverie side. I J } Signed X_� _ Title: �/`� Date: J /`- �`d�i„ FORD RTMENT S_E ONLY z Application Accepted by } Date ��r✓ � _ Area Pit or Grout Inspection by Date Final Inspection by Date b� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 . 0 Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i FEE?NFO AMOUNT DUE AMOUNT REMITTED CK 9 ASH RECEIVED BY t DATE PERMIT NO. +.EH13-241REV.linfir 3-5�d0 `�/ &_ EH 14-28 /y