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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE i 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. TNs application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District. ' Crty Q' � Lot Size � PM ��V Job Address Owner's Nam ress Phone Contractor iddress d License No'3_�� Phone Ve-33 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION JA PUMP INSTALLATIN f SYSTEM REPAIR LlT ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE —A 'sA FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS � INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout k r -^ ❑ Irrigation ---Approx. Depth, Eastern Surface Seal Installed by Repair Work-Done`:'.❑"L�7ype of Pump H.P. y� Sta ok Done I Well Destruction , ❑ Well Diameter Sealing Material (top 501 ¢ I Depth Fille'r•Material_{Below 50'} �- F TYPE OF SEPTIC WORK: NEW INSTALLATION 0"'REPAIR/ADDITION ElDESTRUCTION 11 (No septic system permitted if public sewer is 1. available within 200 feet.) I Installation will serve: Residence— Commercial_ Other ez (dumber of living units: Number of bedrooms 5 E' Character of soil to a depth of 3 feet: ` - Water table depth SEPTIC TANK 11TypelMfg �` Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE C3 No. lenth/size No. & Length of lines 9 FILTER BED ❑ Distance to nearest: Well Foundation Property Line ` SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line R $ DISPOSAL PONDS ❑ ' I hereby certify that I have prepared this application and that the work will be done in accordance with_Sart Joaquin county ordinances, state laws, and ' rules and regulations of the San Joaquin Local Health District. '� ,p 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." Contractors hiring or sub contracting signature' certifies the following:"I certify that in the performance of�te w for which this permit is issued, I shall employ persons subject to workman's compensa` I tion laws of California." The applican ust call r all required inspect( s. Com drawing on everse side 3 1 Signed Title: Date: r FOR DEPARTMENT USE ONLY ,Q "I. �� Application Accepted by Date �� Area Pit or Grout Inspection by Date Final Inspection by�� ate GUS Additional Comments: El Stk 466-6781 Q Lodi `3643621 11 Manteca 823-7104 ❑ Tracy 835-6385 I 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 ASH = RECEIVED BY PATE PERMIT"NO. y INFO �f (f /� p + EH 13-24(REV.1/651 ^7s/✓ `E I-� EH 14-28 /// -