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APPLICATION FOR PERMIT SAN JOAQUINmLOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. A x/ [' J Job Address /�S',0:3 Al �L4s@'� City �� Lot Size a PM 1 Owner's Name L�IVO �t + Address n' Phone /t� .-S') Contractor .S Address G� � ! � License No3 �r� Phon 1'f TYPE OF WELL/PUMP: NEW WELL X WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION>< SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK / 8 SEWER LINES DISPOSAL FLD./ t PROP- LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS * INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation /L Dia. of Well Casing VzDomestic/Private XGravel Pack ❑ Tracy Type of Casing /OVC Specifications f'1 Public n Other Cl Delta Depth of Grout Seal O Type of Grout I I I Irrigation 'L4N ..Approx. Depth I I Eastern Sur/ace Seal Installed by t a - Repair Work Done ❑ Type of Pump SLV� H.P. � h^ State Work Done _ T Well Destruction ❑ Well Diameter Sealing Material (top 501 1 Depth Filler Material (Below 501' TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION'[ I DESTRUCTION 1-I (No septic system permitted if public sewer is 1 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: ` ~Water table depth i' SEPTIC TANK ❑ Type/Mfg Capacity ; No. Compartments r PKG. TREATMENT PLT. ❑ 3 :Method of Disposal Distance to nearest: Well Foundation Property Line O a LEACHING LINE ❑ No. 8r Length of lines Total length/size � X FILTER BED ❑ Distance to nearest: Well Foundation ' Property Line F � 1 SEEPAGE PITS l 1 Depth' Size Number d r 1 SUMPS ❑ Distance to nearest: Well Foundation — Prey Line DISPOSAL PONDS ❑ - .—"J U + I hereby certify that I have prepared this application and-that the work will he done in accordance with San Joaquin county ordinances, state laws, andN 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, 1 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,l shall employ persons subject to workman's compensa- tion laws of California." r The applicant must call for all re ired inspections. Complete drawing on reverse side. Signed Title: 6!rAZ - _ Date: 37 r f FO ARTMENT USE ONLY G Application Accepted by \� � Date 3"�� ` Area � Pit or Gro Inspection by ( A DateG Final Inspection by 12& Date ' '6 111111 q t � _ Additional Comments: j ❑ Stk 466-6781 ❑ Lodi 1369-3621 ❑ 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 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED 13Y DATE PERMIT'NO. INFO +:EH 13-241REV.1"151 ' EH 14-2a