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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (2091466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) i 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.649 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin E Local Health District. P Al �_3-- iq-T, Job Address c..f City Lot Size PM 'to-T S Owner's Name —rim ISS_ Address Phone y r Contractor's Name I License No, Phone — ' .TYPE OF WELL/PUMP: NEW WELL ] WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATIONL SYSTEM REP I�j� OTHER ❑ 7 j DISTANCE TO NEAREST: SEPTIC TANK QQ r SEWER LINES ��fDISPOSAL FLD�-�D"_ PROP. LINE j_17 �. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE' TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial Open Bottom 13 Manteca Dia. of Well Excavation - Dia, of Well Casing `6i'Domestic/Private ElGravel Pack C1Tracy Type of Casing wCdelSpecifications ' ❑ Public ❑ Other ❑ Delta Depth of Grout Seal I TTy e of Grout t 13Irrigation 24�Approx. Depth ElEastern Surface Seal Installed by Mi Repair Work Done ❑ Type of Pump _:5E3 Jb - H.P. State Work Done Well Destruction ❑ Well Diameter ' Sealing Material (top 50') I Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION C-(No septic system permitted if,public sewer is - p0 ` r available within 200 feet.) Installation will serveResidence 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..Compartrtments ' PKG. TREATMENT PLT. ❑ Method of Disposal—. s Distance to nearest: Well Foundation Property Line 0 LEACHING LINE ❑ No. & Length of lines f r Total length/size 1 �. FILTER BED ❑ Distance to nearest: Well Foundation Property Line A SEEPAGE PITS ❑ Depth Size l Number T y 'SUMPS ❑ Distance to nearest: Well Foundation Property One i IDISPOSAL 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. I I 1 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." I :'% iThe applicant my call for for all required inspectieas. Complete drawing on reverse side. F Signed [ � � --- Title: S G Date: it f FOR DEPA TMENT USE ONLY ed A licati Appon cceptby "�' _ Date �' Areeaa��. Pit or ou spection by Datey l Final Inspection by `'- Date r� Additional Comments: fi❑ Stk 466-6781 ❑ Lodi 369-3621 El 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 CK RECEIVED BY DATE PERMIT N0. INFO CASH p { EH 13-24 1426{REV.10!831 EH