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APPLICATION`-FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 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 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. e Job Address City G Lot Size f � PM Owner's Name Address �x } Phone i' i { Contractor�,.�,r�IJL�� Address �d License No. Phone TYPE OF WELL/PUMP: NEW WELL LJ WELL REPLACEMENT ❑ DESTRUCTION ❑' PUMP INSTALLATION ❑W^.. =-s-� �.SY,ST.EM REPAIR L2y� OTHER ❑ DISTANCE TO NEAREST, SEPTIC TANK w SEWER LINES �• DISPOSAL FLD. PROP. LINE .FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE r TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION.S-,. F-1 Industrial I LJ Open Bottom ❑ Manteca Dia. of Well Excavation '� Dia. of WelkCasing Domestic IPrivate� ID Gravel Pack ❑ Tracy' Type of Casing Specifications ElI '1 Public ❑ Other f.-1 Delta Depth of Grout Seal i `u Type of Grout _ ' I I Irrigation r _Approx. Depth I 1 Eastern Surface Seal Installed by i Repair Work Done ❑ Type of Pump •H.P. State Work Done _ W 3 Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material {Below 51l TYPE OF SEPTIC WORK: NEW INSTALLATION'S REPAIRIADDITION [ I `DESTRUCTION I 1 iNo septic system permitted'if public sewer is available within 200 feet.),-, ' Installation will serve: Residence k<"Commercial .Other " t Number of living units: Number of bedrooms _ a depth ' Character of soil to a depth of 3 feet: d !� bWater table SEPTIC TANK—' �` ❑ Type/Mfg Capacity-1 4"0 No Compartments PKG. TREATMENT PLT. ❑ r 1'' Method of Disposal } w " tom.. — ti �� X rt r " Distance to nearest: Well Foundation d flroperty L•ine LEACHING LINE P-"'No. & Length of lines " L ' Total fen th/size FILTER BED ❑ Distance to nearest:--' We��Foundation ( Property Line: ; 01 SEEPAGE PITS y °Deth j C Size ! �� Number SUMPS Ll Distance'to'nearest Well Foundation Property Line i 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 a 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 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 tomorkman's compensa- tion laws of California:" The applicant.must call for all equire 'nspections. Complete drawing on reverse side. ^ � r F Signed X ' Title: _�� !Date: . I — - l 1 E FOR-DEPARTMENT USE ONLY Application Accepted by Date Area r' - Pit or Grout Inspection by date Final Inspection by 4 Date Additional Comments: w❑ Stk 466-6781 ❑ Lodi 369-36210 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 _ RECEIVED BY DATE PERT'NO. GK a INFO .-.-CASH._.) . EH13.21Illr/nbl 776 EH 14-2B i Y �„