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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA \ Telephone (209) 466-6781 1 // PERMIT EXPIRES 1 YEAR FROM DATE ISSUED TrroMnst'L e) 41 Application is hereby made to the San Joaquin LocN Health District for a p rmit and or install the work herein described.This application is PP 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 Districttp ` /-� Q / Q �aQ �3E� Job Address /��0J� �t/ �� + �/c�ty!t` Q�� Lot Size .200 PM a Owner's Name/ y Address 01!R� Phone e Contractoro� C•�2 /,j Z�ddressc�'S �� z_� License Nom �,/ `J Phone I f TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION �� SYSTEM REPAIR (J OTHER ❑ "k DISTANCE TO NEAREST: SEPTIC TANK O/�� EWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI_ONj, ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation _— Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing,��-�-� Specifications FI Public ❑ Other Cl Delta Depth of Grout Seal 1.S Typ of Grout I I Irrigation __Approx. Depth99l®®I Eastern Surface Seal Installed by 4 - Repair Work Done EJ Type of Pump _069 H.P. 02 State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) 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 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation 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 laws, d 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, 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 must call for all required inspection . mplete drawing on reverse side. Signed X Title: Date: FOR DEPARTMENT USE ONLY / ^� Application Accepted by Date �' 1 7 Area ` C 9r \ - Pit or Grout Inspection i,•, Dater Final Inspection by Date �1.+! o� Gv r��c�.v r. r-- �J�` 6 ��I Additional Comments: ElStk 466-6781 ❑ Lodi 369-3621 11Manteca 823-7104 ❑ Tracy 835-6385 �� eel Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMITNO. INFO CASH + EH 13-24)REV.I/s 5) EH 14-2e