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$I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT r 1601 E. HAZEL T 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 Locaf 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 M Local Health District. Job Address A3Z3City Lot Size PM_ Owner's Name _ 3611M _ Address Phone r ContractorsddressPhone 8_9fQ a p ( �i License No,�- Q6�•- Q � TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION i� _,SYSTEM REPAIR ❑ OTHER ❑ G~ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LiNE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS w INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS w ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation g Vr�,�,//�� Dia. of Well Casing Qomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i`l Public (7 Other C-1 Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth { I Easternl JSurface Seal Installed by W �} Repair Work Done � Type of Pump H.P. ` ` State Work Done I Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Fille(Material (Below 50.1 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION 1 } INo septic system permitted if public sewer is t available within 200 feet.) Installation will serve: Residence=Comme'rcial Other_ f Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: .r Water table depth SEPTIC TANK ❑ Type/Mfg Ca acit p Y No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING'LINE ❑ No. & Length of lines Total length/size FILTER BED' ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Cl Distance to nearest: Well Foundation Property Line 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 f 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 his permit isTissued, 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." The applicant must c I r all required j pections. Complete drawing on reverse side. Signed X_ t Title: - Date: OR DEPARTMENT USE ONLY l Application Accepted by Date -J Area Pit or Grout inspection by ate Final Inspection by ate-�c I Additional Comments: t ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 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 Csk INFO ASH RECEIVED BY DATE PERMIT'NO. +.EH13-24fREV.r/x5] 3S`-� � - � EH 14-26 - .. • - 'f !� d- 13-3-5'