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r a` APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 y I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' N' (Complete in Triplicate) ' Application is hereby made to the San Joaquin Local Health District for a permit t onstruct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordina ce No.549 for sewag or 8 ! the Rul sand Regulations of the San Joaquin rl ocal Health District. 2 F, ,. ,,f/�y//�� 1�d°ress `3 City/�F�/ti6t Size o�� M Job Ad > �Plione I I !- Owner's Name ss - Nam, ' cen � �,� � .P..tlona., Contractor's. se No , ' Fa TYPE OF WELL/PUMP: NEW WELL �� WELL REPLACEMENT ❑ _w DESTRUCTION ❑ - PUMP INSTALLATION �— SYSTEM REPAIR BOTHER ❑ f DISTANCE TO NEAREST: SEPTIC TANK Ala 4 SEWER LINES OISPOSALrtFLD. PROP. LINE ' FOUNDATION AGRICULTURE WELL OTHER WEL-L� � PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO S ❑ Industrial 1;1,- Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing G. s_u - Specifications t, omeec/Private ❑ Gravel Pack ❑ Tracy Type of Casing y ❑ Public � ❑ Other ❑ Delta Depth of Grout Seal "'J� Type of Gr ❑ Irrigation approx. Depth ❑ astern Surface Seal Installed by 1 Repair Work Done ❑ Type of Pump M.P. 2 State Work Done t Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 4' available within 200 feet.) r 4 installation will serve: Residence_ Commercial— Other Number of living units: . Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments h KG. TREATMENT PLT. ❑ Method of Disposal r{ t Distance to nearest: Well Foundation Property Line f LEACHING LINE ❑ No. & Length of lines Total length/size i FILTER BED ❑ Distance to nearest: Well Foundation Property Line \ SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ t 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, ('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. Co le drawing on reverse side. L' Signed Title: Date: FOR DEPARTMENT USE ONLY V ] A Application Accepted by Date ` Area Pit or Grout Inspection by Date + Final Inspection by 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 i FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'N0. INFO j il71�r t EH 13-241REV.10/931 '`� % ^� /V -1 1 1 EH 1426