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APPLICATION FOR PERMIT 1 SAN JOAQUIN LOCAL HEALTH DISTRICT bol 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 v 1 made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin p 4 r Local Health District. .. t , , I �] 't . A7U Job Address '�+ City Lot Size& PM Owner's Name r -�/ -� Address �• ' '"" Phone l f1_ Address D r , 3(v 5W Contract _ Aat �.o ` 5 License No. Z Z Phane i TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ J DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE l FOUNDATION - AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ter; ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private d Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout t ❑ Irrigation __4pprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 f TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence tl-- Commercial her Number of living units:s:�� Number of rooms Character of soil"to-a depth'of,3 feet:- Water table depth..• — SEPTIC TANK ___µ,_®',~,;_.Type/Mfg - Capacity �� No. C(impirtrrienti 2 PKG. TREATMENT PLT. © . ; _ �,`-� Method of Disposal -'Distance to to nearest: Well i Foundation / Property Line S' i LEACHING LINE e"-No.: & Length of lines__ ` clot-, R Total length/size x' :-.c�3 F S FILTER BED 11 ;Distance to nearest: WeA _._— Foundation LD _ Property Line _ 1 SEEPAGE PITS ®Depth 25- -Size ` '--Number SUMPS ❑ 'Distance to nearest: Well /�- Foundation /O ~Property Line", a5 DISPOSAL PONDS ❑ .4 I 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 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." The applicant m st call for r ired inspections. Complete drawing on reverse Si4q. Q Signed Title: Date: k) U FOR DEPARTMENT USE ONLY D Application Accepted by Date Area q l Pit or Grout inspection by Date Final Inspection by Date ` r r N& V Additional Comments: ❑ Stk 466-6781 'Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 8354M Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA"95201 I IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT N0. + EH 13-24(REV.1/8 5) EH 14-28