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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT .,,,`,.1601 E.-HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED t . �- (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. �,, •..,,� x Job Address City — Lot Size PM Owner's Name Address Phone )f ,� IF �) k�t � - '_' Contractor's Name icense No, "b Phone V TYPE OF WELL/PUMP: NEW WELD ❑ IWELL REPLACEMENTa.. ---DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPrA ❑ OTHER ❑ DISTANCE TO NEAREST:.SEPTIC TANKSEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca pia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack 11Tra4 Type of Casing Specifications _❑ Public17Other 1:1Delta Depth of Grout Seal Type of Grout)Q01 I ❑ Irrigation --%�Approx�-Depth:s=O-Eastern• Surface Seal Installed by Repair Work Done ❑ Type of Pump " H.P. i' State Work Done Well Destruction ❑ Well Diameter L Sealing Material {top 501 1 Depth Filler Material 1Below 501 �J TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION,❑ DESTRUCTION ❑ (No septic system permitted if public sewer is C Iavailable within 200 feet) Installation will serve: Residenc Commercial Iff,/Other Number of living units: Number;of bedrooms Character-of soil to a depthof 3 feet: /� Water table depth SEPTIC TANK 11 Type/Mfg 1 Capacity-1 ci,a,0 No. Compartments r� PKG. TREATMENT PLT. ❑ Method of D.LSP6sal Distance to nearest: Well.J— Foundation I J2 Property Line LEACH.�tN}G LINE ❑ No. & Length of lines r. Total length/size F�LTER'BEQik ❑ Distance to nearest: Well_ 1 Foundation s-_—__,Property Line SEEPAGE PI!NDS tJ Depth Size C Number 5UMP5 > ❑ Distance to nearest: Well Foundation V Property Line DISPOSAL ❑ . _ I hereby certik 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. % Hvme a+n 4_4-;4 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 &4 : i. �.certifibs the following:"I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant m t for all;:requi pections. Complete rawing on r a side. y 5 Signed � �" """ .. - Date: r FOR DEPARTMENT USE ONLY Application Accepted by 1 Date A/a—C ii or Grout Inspection by DateSFinal Inspection by Date?�5` Additional Comments: ❑ Stk 466-6781 ❑ Lodi 389-3621 ❑ 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 BY DATE PERMIT'NO. INFO CASH + EH 13-241REV.101831 - EH 1426 t.