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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR .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. L �- �7City Lot Size PM Job AddressA,60�_, Address .� Phone Owner's Name / o , Conlrac r r Address to y License No.,,32�7174' Phonq- &9 - "+� TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION El 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 , 17 Public n Other ❑ Delta Depth of Grout Seal Type of Grout — I i Irrigation —Approx. Depth - t I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P, State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 501 Depth iller Material {Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION f-1 IREPAIP/-ADDITION ' DESTRUCTION I 1 iNo septic system permitted iF public sewer iS e - available within 200 feet.) Installation will serve: Residence Commercial. ;, then Number of living units:.. r —Number-ofedOms. - Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg ' Capacity No. Compartments PKG. TREATMENT PLT. ❑ " ,��y�. Method of Disposal Distance to nearest: Wellh�- Foundation Property Line . t LEACHING LINE ❑ No. & Length of lines. i Total length/size f FILTER BED ❑ Distance to nearest: ;Well Foundation Property Line SEEPAGE_ PITS I I Depth SizeyZ S Number i SUMPS Distance to nearest: Well s Foundation - Property Line .�— f. 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,1trict. u.. —. 2 ,• Home owner or licensed agent's signature certifies the following:"I-certify that in�tlie-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'614ornia."Contractor's hiring or sub-contracting signature 1 certifies the following: "I certify that inathe performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." wx The applicant mut all for all fired r spections. Complete drawing on_reverse e si _. Signed X Title: Date: ! 'FOR q PARTMENT USE ONLY plication Acce ted by ( Date Area x / / dor Jout�nspection by r Date`` C!"� Final inspection by` Datef Additional Comments: I ❑ 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 FEE AMOUNT DUE AMOUNT REMITTED 0 CASH RECEIVED BY DATE PERMT NO. I INFO . � +.EH 1324(REV.1/H 5) /1-a EH 14-25