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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 'r1 1601 E. HAZEL T ON AVE-, STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 'I'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. rap Job Address City Lot Size PM Owner's Name Address Phone Contractor _� lL Address License No Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION D • 1 i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE l A FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r I ❑ Industrial r ❑ Open Bottom ❑ Manteca, Dia. of Well Excavation Dia- of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ('1 Public i ❑ Other Ll Delta Depth of Grout Seal Type of Grout _ I 1 Irrigation —.-Approx. Depth i I Eastern Surface Seal Installed by s Repair Work Done ❑ Type of Pump Ft.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') 3 Depth 1. Filler.Material (Below 501 a TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I I INo septic system permitted if public sewer is ( _ available within 200 feet.) tin Installation will serve: Residence! Commercial— Other Number of living units: _)_ Number of bedrooms `13 l Character of soil to a depth of 3 feet: o A 4 Water table depth P SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ �.�, % �j Method of Disposal Distance to nearest: Well 'ts7/?/ Foundation6 Property Line , LEACHING LINE No. & Length of lines T _ T,ottalllle�ngth/size FILTER BED , Disiarice to nearest: Well �Foundation Property Line SEEPAGE PITS i I Depth Size T Number-, ` SUMPS ❑ Distancelto nearest: Well _'Foundation 'iProperty Line' �. DISPOSAL PONDS ❑ I hereby certify that I have prepared this application_and that the work will be done in accoe w _rdaricith San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin L'odal'.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, I shall employ persons subject to workman's compensa tion laws of California." 1 , The applicant must call for a require inspections. Complete drawing on reverse side:_" + Signed X Title: f��—-=�f 7 'Date:,' � �^- f F DEPA MENT USE ONLY ' a = /� Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date�� Additional Comments: LI Stk 466-6781 ❑ Lodi 369-3621 O Manteca 823-7104 ❑ Tracy 835-6385 i Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE � INFO AMOUNT DUE, CK ``". AMOUNT REMIftED ' CASH RECEIVED BY DATE PERMIT'NO. s{ 13241REV.1/_N51Yqd 'EH 14-2e a