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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 welUpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address City Lot Size gaqAIA PM Owner's Name Address It.qE ! A2 V_,U�4) Phone Contract ' ' 4 Address!. License No.307PC96 Phone,36 9~1/o 0 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 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 171 Public 171 Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation _..Approx. Depth TI Eastern f Surface Seal Installed by Repair Work Done ❑ Type of Pump y H.P. _ _ State Work Done_ Well Destruction ❑ Well Diameter Sealing Material [top Depth --" 'ler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I� REPAIR ADDITION DESTRUCTION I 1 iNo septic system permitted if public sewer is Y/ available within 200 feet.) C Installation will serve: Residence_ Commercial_ Other .- Qv Number of living units: _/_ Number of b rooms �l Character of soil to a depth of 3 feet: Water table depth V SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments 'QJ PKG. TREATMENT PLT. ❑ R Method of Disposal Distance to nearest: Well Foundation Property Line Q LEACHING LINE �No. & Length of lines Total length/size eV r I FILTER BED ❑ Distance to nearest: Well Foundation JO Property Line 1 SEEPAGE PITS i I Depth Size Number 1m SUMPS 0 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 Cali rnia." The applicant m t all for all uire inspections. Complete drawing on raver Pe. Signed Title: Date: FOR DEPARTMENT USE ONLY �{ Application Accepted by Date /� -2-4y" ° Area 7J�~ Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2409, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. + EH 13-241REY.v/Ms1 --� p p Q g� l5'� EH 14-28 ° f