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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. Job Address eNo /w)C (,. _ _ . City _,eff oliD�ift Size PM Owner's Name Q � Address Phone .67e Contractor /} 5 Address License No. l Phone TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENTX DESTRUCTION ❑ _J PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ �}�E DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLID UNDATION Z AGRICULTURE WELL -:!—'— OTHER WELL— PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS / f( CI Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ` Dia. of Well Casir� l LJ Domestic/Private Gravel Pack El Tracy Type of Casing Specification LL I.1 Public 11 Other n Delta Depth of Grout Seal Type of Grout Irrigation .1Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump §WIE H.P. State Work DDo�ne Well Destruction ❑ Well Diameter Sealing Material {top 50') ��1 ma9mc— %VL Depth �5'2 Z� Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRYADDITION I ) DESTRUCTION I I iNo septic system permitted if public sewer is available within 200 feet.) 0 Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments C�iV PKG. TREATMENT PLT. ❑ Method of Disposal f Distance to nearest` Well Fou6da-ion Property Line 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 Ll 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 4shalln rules and regulations of the San Joaquin Local Health Di§trict. 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 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." The applicant st �I requir=sComplete drawing on reverse ` /20 Signed X le: Date: r S FOR DEPARTMENT USE ONL Application Accepted by Il Dat`e�� Area Pito Grout Inspection by Date g Final Inspection by " bate (� Z-�f 45 Additional Comments: � ! -� 7 3 �� }c.,�Dyr (4,96 ❑ Stk 466-6781 ❑ Lodi -3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 7 0T Applicant - Return all copies to: Environmental Health Permit/Services 1 1 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 ' INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE pl �/ +.EH 1 3-24 tREV.t/k 51