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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED k (Complete in Triplicate) 1 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 sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. t I . Job Address �f /�- City tot Size PM 13 Owner's Name L[cc�- �,gs Address Z Phone �`"� � Contractor Address �� SGL License No. PPa Phone°2 TYPE OF WELL/PUMP: NEW WELL LlWELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES. DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS 4 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 5(Domestic/Private ❑ Gravel Pack ❑ Tracy + Type of Casing, Specifications `� r - - I I`1 Public Ll Ofhgr ❑ Delta-, �,:-Del ih•'ofy,Grout Seal _.:Type-of Grout t x. De ih I i Eastern Surface Seal lnstalled,by - I ! Irrigation �--Apfxor A Repair Work Done Type of Pump-Q��- H.P. State Work Done P r Well Destruction ❑ Well Diameter $ Sealing Material atop 50 ,,,. Depth Filler Material 1Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I'1 REPAIR/ADDITION E I DESTRUCTION,-.Il (No septic system permitted if public sewer is V I available within 200 feet.) Installation will serve: Residence Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: s r Water table depth SEPTIC TANK ❑ Type/Mfg Capacity' 2 A— 'No. Compartments PKG. TREATMENT PLT. ❑ � �• `t 1 t;~ Method of Disposal t Distance to nearest: Well Foundation `y Property Line LEACHING LINE ❑ No. & Length of lines Total'length/size FILTER BEI7 ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size _ Number SUMPS L❑ Distance to nearest: Well Foundation 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, and rules and regulations of the San Joaquin Local Health DiWict. 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 it the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call f9#1ail required inspections. Complete drawing onre arse side. Signed X Title: Date: �EPARTMENT USE ONLY Q� `,.Application Accepted by Date U/ Area� Pit or Grout inspection by Date 'le Final Inspection b Dat -, Additional Comments: T ♦� ❑ 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 7 AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMITNO. r 2 �.EH 13.241 REV.1/851 INFO 3-5 1 ,�9 EH 1I-26 t -