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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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. I" Job Address_," �0 D City 'd___Lot Size PM Owner's Name .�/ _ Address Phone Contractor r _ AddressG3 L?cjicense No.�-2— Phone��-� 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 Li Industrial Ll Open Bottom Cl Manteca Dia. of Well Excavation Dia. of Well Casing *f—omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F1 Public 1-1 Other 1-1 Delta Depth of Grout Seal _ Type of Grout Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump _ H.P. [nom State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 f Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I INo 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 Disposals- Distance to nearest: Well Foundation Property Line11 i»p3 { LEACHING LINE ❑ No. & Length of lines Total length/size ((gy)pp FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size _ Number ; SUMPS LI Distance to nearest: Well Foundation Property Line{yk FT�^ _lHEArLIT1 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, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must cacII or all req red inspections. Complete drawing on reverse side. Signed X///-c-=-"��U///l�C/ice Title: eU4._ Date: FOR DEPARTMENT USE ONLY Application Accepted by , ' rl Date Area / Pit or Grout Inspection by Date Final Inspection by Da�Ie 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, Stk., CA 95201 C FEE AMOUNT DUE AMOUNT REMITTED CK INFO CASH RECEIVED BY DATE PERMIT NO. l ♦ EH 13-241REV.rin51 3s(jv C � EH 14-28 �•NI"YJ O-