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APPLICATION FOR PERMIT E :S SAN JOAQUIN LOCAL HEALTH DISTRICT !' 1601 E. HAZEL T ON AVE„ STOCKTON, CA NO trw��n Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED h' r (Complete in Triplicate) Application is hereby made to the San Joa quin Local Health District for a permit to construct andlor 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. / '7 ��+—fes! Job Address { �� __ __ City Lot Size PM Owner's Name .1x ✓�? Address ' C Phone '{ Contractor l Address License No, Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK!- SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL — . .OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottomm: EJ Manteca Dia. of-Well Excavation Dia: of Well Casing Irl Domestic/Private LlGravel Pack ❑ Tracy Type of Casing Specifications — 1-1 Public Cl Other l l Delta Depth of Grout Seal Type of Grout_ I I Ifrigation _.-Approx. Depth l I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump i H.P. State Work Done Well Destruction ❑ Well Diameter + Sealing Material (top 50') Depth l I Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION (1 REPAIR/ADDITION l I DESTRUCTION Wo septic system permitted if public sewer is `, available within 200 feet.) Installation will serve: Residence_r Commercial_ Other t� Number of living units: Number+of bedrooms 1 (� Character of soil to a depth of 3 feet: 4 Water table depth V' SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ :1 Method of Disposal Distance to jl earest: Well Foundation Property Line _ LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to`_nearest: Well Foundation Property Line v SEEPAGE PITS 11 Depth Size Number l SUMPS El Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ t1'1 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 l 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,l shall employ persons subject to workman's compensa tion laws of California." } The applicant must call for all requi d inspections. Complete drawing on reverse side. Signed X Title: . Date: f� ! t R DEPARTMENT USE ONLY i Application Accepted by Date Area Pit or Grout Inspection by t Data Final Inspection by Date ? Additional Comments: :I ❑ Stk 466-6781 ❑ Lodi 369-36211 ❑ 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 INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. I t ♦.EH 13-241REV.t/N5) s `C .L_171 ' Y ---1hc) -S,3 EH t4-26 �7 i, li ��