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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 (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 Y made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 18.62 for well/pump and the Rules and Regulations oftheSan Joaquin Local Health District. Job Address Lot Size M a Owner's Name ..1�G"+� '" A'ddressPhone r., Contractor _ Address" r TYPE OF WELL/PUMP: w NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 PUMP INSTALLATION.Q SYSTEM REPAIR 0 OTHER ❑ { ' DISTANCE TO NEA IC TANK SEWER LINES DISPOSAL FLD. PROP. LINE q, FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ f ' INTENDED USE t3YPE•OF„WELL PROBLEM ONSTRUC_TION SPECIFICATIONS r i; ❑ Industrial ❑ Open.Bottom ❑ Manteca Dia. o avation ` ' -- Dia. of Well.Casing L' - ❑ Domestic/Private ❑ Gravel Pack ; ❑ Tracy Type of Casing i ” Specifications' ❑ Public ❑ Other ! ❑ Delta Depth of Grout Sea{ of Grout Cl Irrigation - --Approx. Depth ❑ Eastern Surface Seal InstMled_by, �- --- --- Repair Work Done ❑ Type of Pump ..d H.P. State Work Done We11 Desiructlon ❑ Well Diameter 3' �5ealir)gIMaterial (top 50`1 �- Depth � FillerMaterial (Below 50'1 ' } t � i TYPE OF"SEPTIC WORK': INSTALLATION REPAIR/ADDITION ❑" DESTRUCTION ❑ INo septic system permitted if public sewer is.' available within 200 feet's �-installation will serve: Residence ~~ Commercial_ therf Number of living units: V Numbdr of bedroa Character of soil to a de th of 3 feet: ' �'^� p x. Water table depth SEPTIC TANK ❑ Type/Mfg 4"040. t Compartments \ PKG. TREATMENT PLT. ❑ - . ' Method of Disposal Distance to nearest: Well Foundation Property Line .I r LEACHING LINE P-* "No. & Length of lines Total length/size s FILTER BED ❑ Distance to nearest: ell _ Foundation Property Line q .1 SEEPAGEPITSY6epth Size Number SUMPS ❑` Distance to nearest: Well f _ Foundation f®Q '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, an rules and regulations of the San Joaquin Local Health District. i 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 notZ employ any person in such manner as to become subject to workman's compensation laws of California.".Contractor's hiring or sub-contractingsignature 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." 4. 1 /. . The applicall fora uire i qpecti ns. Complete drawing on reverse side. t i. Signed X itle: 402-20111-11 _ Date:NJ FOR DEPARTMENT USE ONLY j r � Application Accepted by � n Date _ '`- _� �+] Area s i Pit or Grout Inspection by "ate 17 Fmal I nmectinnftvate n� r• Additional Comments: V -� �'� - - ❑ Stk 466-6781 ❑ Lodi 369-3621 El Manteca_ -7104 ❑ Tracy '835-6305 Applicant- Return all copies to: Environmental'Health Permit/Services 1601 E. Hazelton Ave.,,P.O. Box,2009, Stk., CA 95201FEE _ r INFO AMOUNT DUE MOUNT REMITTED K RECEIVED BY+'^° x DATE" �'PERMIT'NO. + EH 13-24{REV.tits 57 J o ��~ .. ��.� ��..� 7--- 87 ` EH 14-28