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h f 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 F made incompliance 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 ealth District. n k Job Address � I F� ems` City a Lot Size PM F Owner's Name h t� Address C) Phone l` 7 I Contract Address Z ��c to� f/�U�` t`License No.: ?� Phone C�� 701 r TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ i f DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ j INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �i ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack DTracy Type of Casing Specifications ; I'] Public ❑ Other [--]-,Delta Depth of Grout Seal Type of Grout t I I Irrigation --Approx. Depth I 1 E stern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump `' H.P. State Work Done _ Well Destruction ❑ Well Diameter N Sealing Material Itop 501 Depth S Filler Material {Below 50') _ TYPE OF SEPTIC WORK: NEW INSTALLATION' REPAIR/ADDITION i 1 DESTRUCTION l I INo septic system permitted if public sewer is i - - available within 200 feet.) installation will serve: Residence Commercial.- ,Other 1 Number of living units: _L_ Number of lRprooms, /V # Character of soil to a depth of 3 feet: ti -•vaa Water table depth �U f SEPTIC TANK Type/Mfg � `" 5 -.= JCapacity--.&L'd No. Compartments PKG. TREATMENT PLT. ❑ t_. .. .:__ r r Method of Disppsal Distance to nearest Well_ Foundation /t! Property Line_ LEACHING LINE No. & Length of lines ''t 0 Total length/size d X 2 FILTER BED ❑ Distance to,nearest'. Welf'��.- Foundation Property Line S� } SEEPAGE PITS Depth .t r - ; Sim � Number y SUMPS ❑ Distance to nearest: Well an Foundation_---r D' Property Line a DISPOSAL PONDS ❑ + *R 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, 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.certi y that in the` rformance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion 9 p P Y P 1 P tion laws of California."#,.� t The applicant must 11 for all- uir inspections. Complete drawing on reverV e� (� Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by 1 r��rT' _ Date T / Area / I �i or Grout Inspection by ate6 Final Inspection by -'! Date Additional Comments: — ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I� INFO FEE AMOUNT DUE AMOUNT REMITTED CASH CK 4 RECEIVED BY DATE PERMIT•NO. S r EH13-24(REV.i/H 57 q 5 EH 14.26 Lo C