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l APPLICATION FOR PERMIT '_` SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA �G4� Telephone M9) 4866781 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 istrict.So 41 )r ff C�CJI City C' Lot Size PM Job Address J (� } Owner's Name Address L I `' ` -- Phone Contractor - Address License No. Phone_ TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION NZI PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHE ❑ 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 F-1Industrial LlOpen Bottom C] Manteca Dia. of Well Excavation Dia. of Well Casing 171 Domestic/Private Ll Gravel Pack `_� Tracy Type of Casing Specifications �1 Public i-I Other 1-1 Delta Depth of Grout Seal Type of Grout I I irrigation _ Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done [-1 Type of Pump H.P. -- State Work Done— Well Destruction ❑ Well Diameter _ Sealing Material (top 50') Depth Filler Material (Below 501 _ -- TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REF41R/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 fee ..1-- Installation will serve: Residence__ Commerciai___ Other Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ y ___ Capacity_ No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distanc7tonea; Well oundation_ Property Line LEACHING LINE o. & Length of lines FILTER BED ❑ Distance to nearest: Well _ Foundation Propert SEEP E PITS ! I Depth Size �_--� — Number SUMPS L] 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 D,%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, 1 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, I shall employ persons subject to workman's compensa- tion laws of California." The applicant mu or all require i spections. Complete drawing on reverse side. Signed X�[/ //GL _ Title: Date: ' T� FOR DEPARTMENT USE ONLY / ✓ t c l Date Area Application Accepted by � Pit or Grout Inspection by _ t Date— _ Final Inspection by '� Date' `Y 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 2009, Sik., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. jT . INFO +.EH 13.24(A EV.t/m b) � ` Q EH 14-26