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APPLICATION'FOR.PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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 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 Says Joaquin Local Health District. � � � r'� ll� p1G� Job Address City �t`G1 Lot Siz G PM Owner's Name L'\fy-" TS 1p k)V\ Address e h'one Contractor's Name 't1 \ ! Com. License No. Phone TYPE OF WELL/PUMP: I NEW�WELL;'_,_ WELL REPLACEMENT `DESTRUCTION 17) � PUMP INSTALLA_ TION ❑ LINES DISPOSAL REPAIR,-.0. , OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER S DISPOSAL FLD PROP. LINE FOUNDATION— ` AGRICULTURE WELL OTHER WELL PITS/SUMPS N INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS it tA ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavat n Dia. of Well Casing DQ Domestic/Private Gravel Pack Tracy Type of Casing _ Sp�ecifications ` ❑ Public ❑ Other ❑ Delta Depth of Grout Seal 7�fiype of Grout p ❑ Irrigation �4pprox. Depth ❑ Eastern Surface Seal Installed by E� Repair Work Done ❑ Type of Pump H.P. State Work Done Wel Destruction ❑ Well Diameter Sealing Material (top 50') �Gl Filler Material (Below 501 TYPE F EPTIC WORK: NEW INS AL TIO Pell REPAIR/ADDITION ❑ 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: i Water table depth SEPTIC TANK ❑ Type S I YP 9 Capacity No. Compartments i PKG. TREATMENT PLT. ❑ f Method of DIsposal t Distance to nearest: fI it fA: .. Wel! Fou ndation Property Line= LEACHING LiNE ❑ No. & Length of lines 1 ► ` Total length/size FILTER BED ❑ Distance to nearest: WellFvundatiori-r Property Line i e � SEEPAGE PiTS ❑ Depth Size i 1I Number SUMPS ❑ Distance to nearest: Well Foundation =.: ; Property Line DISPOSAL PONDS ❑ r : f - 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 , 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 the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." ! The applicant must cati for all required inspections. Complete drawing on reverse side. �'---w -^- Signed tS'OS ��T!tle. 3—Q Date: FOR DEPARTMENT USE ONLY Application Accepted byQ / ` ,_j�J Date Area Pit or Grout Inspection by Date l' r ' FY Final Inspection by Date 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 qr``C{w FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT'iVO. INFO +EH 1324(REV.101831 �� t�g� � 9/13x! `� 4 EH 14-26 � 1 1 i