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1 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 San Joaquin Local Health District: Job Address ,2= City Lot Size PM Owner's Name �f i �M�al�i�.+c Address Phone 3 _W .t>lOF Contractor Address X -d License No.jf3!R" Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ j PUMP INSTALLATION ❑ SYSTEM REPAIR"❑ " ' "OTHER:❑ ' DISTANCE•TO NEAREST: SEPTIC TANK. SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom D Manteca Dia. of Well Excavation Dia. of Well Casing ID Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public Ll Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation —.Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ r Type-of Pump H.P. State Work Done Well Destruction ❑ Well Diameter "' Sealing Material 1[op 50'1 {V Depth Filler Material {Below 501 TYPE OF SEPTIC WORK:ANEW INSTALLATION 1:) , REPAIR/ADDITION l I DESTRUCTION (No septic system permitted if public sewer is I"`�ti �' � available within 200 feet.) fi Installation will serve: Residence_ Commercial Other �] Number of living units: �Number;of bedrooms t 1 Character of soil to a depth of 3 feet:, Water table depth SEPTIC TANK D -Type/Mfg Capacity No. Compartments 1 PKG. TREATMENT PLT. Ot 4 Method of Disposal DistlInce to 4earest: Well Foundation Property Line 's LEACHING LINE {y ❑ ?No.�& Lengtfi.of lines Total length/size FILTER BED `❑ 'Distance to-,nearest: Well Foundation Property Line SEEPAGE PITS I 1Depth Size Number x SUMPS L1 Distance to nearest: Well _ foundation Property Line ' DISPOSAL PONDS ❑ 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'M%trict. 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 fWwhich this permit.is issued, i shall employ persons subject to workman's compensa- tion laws of California." x ° r The applicant must call for algeqre d irispel ions. Complete-drawing on reverse side. 4± Signed X_ ' Title: Date- FOR DEPARTMENT USE ONLY p. Application Accepted by Date 1 Z3 O' Area Pit or Grout Inspection by ^� Date Final Iny tion by r _ Date__ A., Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 © Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health PermiOServices 1601.E.,Hazelton Ave., P.O.-Box 2009, Stk., CA 9520JVINY�0." FEE AMOUNT'DUE AMOUNT REMITTED T Kl RECEIVEp BY PATE INFO C HEH14-21(REV.r/n5) �� EH 1426 1