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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 , i _ 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. Jab Address ,�� ° PV�c _ City r Lot Size ��K-lao PM Owner's Name f Address Phone /S�f Contss License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 4 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 4 \� ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing t `V I 4V ❑ Dorrlestic/P..rivate,-D-Gravel_Rack:�. ❑ Tracy 3 Type of Casing Specifications C 1-1 Public ❑ Other A Cl Delta -.777 Depth of-Grout-Seal-- Type of Grout 11 Irrigation --Approx. Depth i I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H,P. State Work Dane i Well Destruction ❑ Well Diameter Sealing Material (top 501 ! } Depth �i llvlaterial Blow 50'I TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION I 1 DESTRUCTION (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 f Capacity -�No! Compartments PKG. TREATMENT,'PLT. ❑ t Method of Disposal Distance to nearest:: Well Foundation.- Property Line , V,. LEACHING LINE ❑ No. & Length of lines f Total length/size • t FILTER BED ❑ Distance to nearest: Well Foundation Property"Line o- SEEPAGE PITS l 1 Depth Size r'Number jt SUMPS LDistance to nearest: Well Foundation Property iLine DISPOSAL PONDS ❑ a i 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. I L'. 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 parson in such manner as to become subject to workman's compensation laws of California."Confractor'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 C 'or ia." Theapplica m call for II raqu' �l inspections. Complete drawing on rev rsa side. w Signed X Title: 9ZAV Date: FOR DEPARTMENT USE ONLY f Application Accepted by R C' Date +7 Area Pit or Grout Inspection by Date Final Inspection by Data 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 FEE INFO �AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. + EH 13-241REV.r/n51 - ,,.•J { EH 1428 VVVJ