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APPLICATION FOR PERMIT A SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 456-6781 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 welUpump and the Rules and Regulations of the San Joaquin Local Health District. ,,[•f ,A, _ Job Address �1 1'0-! PO City Te"-c', Lot Size 1 f PM Owner's NameC �"CJ r'" — Address Phone Contractor e►� Address License Na Plione" TYPE OF WELL-/PUMP:-- NEW WELL.❑w_,..,. .,.WELL REPLACEMENT ❑- DESTRUCTIONJ❑ _ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER LJ ► DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE } FOUNDATION t AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE.. TYPE OF,WELl_ PROBLEM AREA CONSTRUCTION SPECIFICATIONS Q I ❑ Industrial El Open Bottom �❑ Manteca Dia. of Well Excavation Dia. of Well Casing I' Specifications .❑,Domestic/Private ❑ Gravel Pack " ❑ Tracy Type of Casing r - l'l Public ❑ Other F1 Delta Depth of Grout Seal Type of Grout s .I _ I ! Irrigation � ..Approx. Depth I 1 fastern.,� �� Surface Seal Installed by ' r t Repair Work Done-'❑_• Type of Pump H,P. State Work Done Well Destruction ❑ _�Well Diameter Sealing Material (top 50')_ l .M,...�..�.......-__aT•--... -.-.r __.,. ....,..tea.-�».w-x. �4.,:. Depth. ': Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION- -R PAIR/ADDITION I I DESTRUCTION { I (No septic system permitted if public sewer is 'f available within 200 feet.) Installation will serve: Residence-K-'Commercial_ Other 3 � Number of living units: —t— Number of bedrooms ! •. F Character of soil to a depth of 3 feet: ��.No. Water table depth SEPTIC TANK ` I�" Type/Mfg " - G * apacityCompartments PKG. TREATMENT PLT. L1 r Method of Disposal Distance to nearest: Well Foundation Property Line ... LEACHING LINE P-INo. & Length of lines ' Total length/si ze lain FILTER BED ❑ Distance to nearest: Well Foundation Property Line 5C) SEEPAGE PITS w. 14"0'Depth Size Number SUMPS Ll Distance to nearest: Well f "Foundation fj! Property Line �n r DISPOSAL PONOS "' ❑ it S{ 1 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. 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,1 shall employ persons subject to workman's compensa ' tion laws of California." r r : The applicant must call for all 1equied"inspections. Complete drawing on reverse side. { Signed X f/I■ - Title: - Date: It FOR DEPARTMENT USEIOONLY t 1 Application Accepted by Date Area Pit or Grout Inspection by Date - Final Inspection by Date F Additional Comments:: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823_7j104 ❑ Tracy 835-6385 1 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT INFO. REMITTED GASH RECEIVED BY DATE PERMIT"NO. + EH 13-241REV.iiA51 ip d+� EH 14-28