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j APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 k PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) 4 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 welUpump and the Rules and Regulations of the San Joaquin Local Health District- Job Address City tec�A**Pot size PM Owner's Name Address Phone u I Corltfactor42,�t � Address_F! A�� .r st'~Cfi License No-�,Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT L1 DESTRUCTION ❑ - �l --- - -PUMP INSTALLATION-G —.-..»a-- SYSTEM REPAIR-.O ---OTHER-.Q— DISTANCE —OTHER-.O-- 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 ❑ Manteca Dia. of Well Excavation Dia. of Well Casing i ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'] Public F1 Other P. i i Delta Depth of Grout Seal Type-of Grout _ I i Irrigation Approx. Depth I 1 Easterrl„_,,T.,.j.Surface Sealanstalled by Repair Work Done L7 Type of Pump H.P. 1. State Work Done i _ Well Destruction ❑ Well Diameter Sealing Material Itop 50') Depth —Filler..Materiai {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION) REPAIR/ADDITION l I DESTRUCTION.1 i INo septic system permitted if public sewer is k, °,;—available within 200'feet.) Installation will serve: Residence Commercial_ Other r Number'of living units: _J_ Number of bedrooms 10, Character of soil to a depth of 3 feet: � �L_ # Water table depth SEPTIC TANK /Mfg Type/Mfg Capacity.._. ?��Q_` No. Gompartments PKG. TREATMENT PLT. ❑, t ! i t� _ `" Method of-Disposal Distance to nearest: Well Foundation L '/$� Property Line .iZS h LEACHING LINE No. & Length of lines .3, 010 �� ,`,,,_ Total length/size FILTER BED ❑ Distance to nearest: Well �LLFounda'tion-- Property Line-_1�la PITS PITS I I Depth Size Number SUMPS LI Distance to nearest: -. Well Foundation Property Line and F DISPOSAL PONDS EJ 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, rules and regulations of the San Joaquin Local Health District. 0 _ 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 must call f all required inspections. Complete drawing on reverse side. ' f Date: Signed Title: s /t> FOR DEPARTMENT USE ONLY Application Accepted by '':'. Date Z—' 6 Ara Z �. Pit or Gro.11 Inspection by Date Final Inspection by Date Additional Comments: i ❑ Stk 466-6781• ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant a Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.0, 2009, Stk., CA.95201 4 j FEE AMOUNT DUE ' AMOUNT REMITTED CK y.. RECEIVED BYDATE PERMIT'NO. s 4' INFO —— CASH E EIA1-241HEV.riy5 EIA 4-26 V Ar I