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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 se ge or No. 1862 f II/pu nd the Rules and Regulations of the San Joa uin Local Healthh District.C�� 4p {� 4 rb tr•i- 'S'rt Z4 vk ©� ,Z J ` ` } Job Address City6�+� Lot Size 2" Z— PM Owner's Name U _ 5�� Addre Phone Contractor � �1t+a S 5 Address S ay ic-se No 34 V' T Phone_ TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ 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 t PROBLEM AREA CONSTRUCTION SPECIFICAT14NS El Industrial ❑ Open Bottom + ❑ Manteca+ /Dia. of Well Excavation Dia. of Well Casing Domestic/Private [ Gravel PockCa y _❑ Tracy Type of sing �.tM_j. Specifications �. M Public ❑ Other Fl Delta Depth of Grout Seal a` Type of Grout9 . 11 I I Irrigation _.Approx. Depth I 1 Eastern r Surf ac Seal Installed by Repair Work Done ❑ Type of Pump .�31 I0 H.P._! State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50'1 y Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I i RFPAIR/ADDITION I I DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ .Other Number of living units: Number o edrooms n Character of soil to a depth of 3 feet: ° 3 ° Water table depth SEPTIC TANK ❑ Type/Mig Capacity J No. Compartments PKG. TREATMENT PLT. ❑ �` �' Method of Disposal Distance to nearest: �' Foundation t Property Line 4� F i V1 LEACHING LINE ❑ No. & Length ines f �' ' Total length/size FILTER BED ❑ Distance nearest: Well Foundation r Property tine F I SEEPAGE PITS I I pth Size + Number SUMPS Fl Distance to nearest: Well T Foundation a Property Line DISPOSAL PONDS ❑ s 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 y 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 must call for all required inspections. Complete drawing on reverse side. w Signed X _., Title: Date: �l FOR DEPARTMENT USE ONLY Application Accepted by _ Date I - Area Pit or Grout Inspection by Date Final Inspection by r . slv Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 i INFO AMOUNT DUE MOUNT AMOUNT REMITTED IIT/TESD CCK# RECEIVED BY //J�DAT/E PERMIT'NO. ..EH 14-241REV,1iws) �,{1✓ 1� • V U lay � aq�IEH 14-28 ii V O