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p � 7 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) i 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 C(unty Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. I Job Address G City Lot Size PM •�/Ad rens Phone Owner's Name ." Address License No._ Phone Contractor TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ f 1 ." v PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ f DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE -TYPE'OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C1 Industrial ,❑ Open Bottom 11 Manteca Dia. of Well Excavation Dia. of Well Casing rT f CasingSpecifications ' ❑ Domestic/Private C3Gravel,Pack ❑ Tracy Type o ❑ Public ❑ Other y ❑ Delta Deplh,of Grout Seal Type of Grout } i:) Irrigation �Approx. Depth ❑ Eastern Surfage Seal Installed by W ' State Work Done P Repair Work Done ❑ Type of ump- H.P. - - z Well Destruction [I Well Diameter = -` Sealing Materiaf',Itop 50'1 Depth I �` Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION, DESTRVCT40N O INa septic system permitted if public sewer is Aril ajvail within f 1 Installation will serve: Residence=! Commercial-. Other Number of living units: - Number of bedrooms_ j1.l' '�.. r,*:. Water table depth Character of soil to a depth of 3 feet: :,-,IleCapacity No. Compartments SEPTIC TANK LJType/II e ! rs '� Method of Disposal 1:1PKG. TREATMENT PLT. A ,. a Distance to nearest: Well '�".Y'•,�o�undation Property tine tri k r F1;, r ! LEACHING LINE � No. & Length�of_line k� a Total length/size r FILTER BED El Distance to nearest: Well Foundation es0 Property Line gpF$ ❑ Depth I Size f�jumber . SUMPS _ . Property Line' Distance to nearest: Well Foundation �f e DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will'he done in accordance with Sawn�Jooaquin county ordinances, state laws, and rules and regulations of the San Joa4uin Local Health District. p 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 woikman's compenssation•-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." uired inspections Complete drawin o `re'erre side.,- The applicant must call for all req Signed ` FOR DE ARTMFNT,..USE ONLY Application Accepted by !� Date Area I final Inspectiox by Date Pit or Grout Inspection by Date f' Additional Comments: r 836-6385 ❑ Stk 466 6781 ❑ Lodi 369 3621 ❑ Manteca 823 71 ❑ Tr cy Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.. P.O. Box 2009,.Stk., CA 95201 FEEAMOUNT DUE AMOUNT REMITTED RECEIVEDCKSH BY DATE" PERMIT`NO. INFO � C + EH 13-24[REV.Ilan) r� , '+ tl EH 54-26