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APPLICATION FOR PERMIT 1 SAN JOAQUIN LOCAL HEALTH DISTRICT t 1601 E. HAZEL 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. ^;r Job Address 6- City Lot Size PM Owner's Name F,�:e Address Phone `07L� 9 ,r Contractor ress OyV 4 ;cense No Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION El 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 FI Public 1-1 Other F1 Delta Depth of Grout Seal Type of Grout _ I I Irrigation __Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth -1--riller Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION I 1 DESTRUCTION l I (No septic system permitted if public sewer is J available within 200 feet.) Installation will serve: Residence / Commercial— Other Number of living units: -I— Number of b drooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ElType/Mfg Capacity-4&P-0— No. Compartments PKG. TREATMENT PLT. O Method of Disposal Distance to nearest: Well le-12 Foundation Property Line 44,9 LEACHING LINE L1 No. & Length of lines � .�®- _ 0 f9 Total length/size FILTER BED ❑ Distance to nearest: Well 6 49 `Foundation Property Line- - SEEPAGE PITS ( I Depth Number SKPPSS), Ll Distance to nearest: WeN/� 4 Foundation Property Line L 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, an 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 f r alled inspections. Com to drawing on reverse side. Signed X Title: Date: FOR DEPARTMENT USE ONLY Applic tion Accepted by 6'�.�t..�,h Date Area Z Grout ns crtion by ? Date Final Inspection by Date Additional Comments: El Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 El Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO FEE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT NO. +.EH 13-24(REV.1/N sl EH 14-26 �_