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a,. APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE.,,STOCKTON, CA 1 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 and the Rules and Regulations of the San Joaquin Local Health District. t Job AddressC �a. Ci Lot SizSL _ PM' 11 i Owner's Name ✓1 Address lS� f� • t�C• +'' f�hone ^�t 11 Contract Address _ License IVo. Phone :TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 11 DESTRUCTION ❑ s ' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ s I (DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LIME # i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _ ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing j ❑ Domestic/Private D Gravel Pack ❑ Tracy Type of Casing Specifications j ❑ Public k ❑ Other ❑ Delta ' Depth of Grout Sea! Type of Grout ❑ Irrigation ,—Approx. Depth ❑ Eastern Surface Seal Installed by NRepair Work Oone L-1Type of Pump H.P. `J State Work Done Well Destruction ❑ Well Diameter Sealing Mate ial (top 501 € Depth Filler.Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑' DESTRUCTION ❑ (No septic system permitted if public sewer is i \"may available within 200 feet.) Installation-will-serve:--Rest ence-^- —Commercial �/�ther, t Number of living units: Number of b ms "7! I Character•of-soil-to-a-depth-of 3•feet: '- - r Water table depth19 f SEPTIC TANK $Y Type/Mfg , /,Capacity/ d O No. Compartments PKG. TREATMENT PLT. ❑ r r " '' . i $ ° f "Kllethod of Disppsal j Distance to nearest: Well 5 Foundation-.,.�� Property Line L-s s ;LEACHING LINE k-,No. & Length of lines Notal length/size FILTER BED ❑ Distance to nearest: Wel! y . . Foundation In Property Line SEEPAGE PITS ( Defth SUMPS EJ: Distance to nearest: Well � Foundation ''Property Line j I F DISPOSAL PONDS ❑ s fx 4 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin countytyordinances, state laws, and -rules,.and regulations of the San Joaquin Local Health District. r .. 1 \ Home owner or licensed agent's signature certifies the.following: "I certify that in the performance of the work:for which this permit isJssued;I shall not employ any person in such manner as to become subject to workman's compensation laws of California."-Contractor's-hiring o7 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 workmahs cbinpensa- tion laws of California." f 11 The applicant t call for all r ired inspections. Complete drawing on reverse sid �,A ' I ! L t� Signed } `� Title: V`�" Dater FOR DEPARTMENT USE ONLY Application Accepted by f Date I Pit or Grout Inspection by Date 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 n � F EE i INFO AMOUNT DUE AMOUNT REMITTED _ CAK RECEIVED BY DATE PERMIVNO. S + EH 13-241REV.ti/951 - - nEH 1428