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j:. 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 Ifl (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 sewage or No. 1862 for weli/pump and-the Rules and Regulations of the San Joaquin Local Health District. I City L J . �� Q 1 LotSize* y PM Job Address ' Address 5ffm e_ Phone Owner's Name J 3 011 ti`,� Phone Contractor's Name License No. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION. ❑ PUMP INSTALLATIyO�N/� SYSTEM REPAIR j OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION 1 AGRICULTURE WELL OTHER WELL— INTENDED INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS El Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Type Casin Domestic/Private El Gravel Pack ❑ TTracy YP of 9 Specifications El Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation J_Ap_ x. Depth Eastern Surface Seal I(stalled"by r i Installed- -t 51� H.P! + _2 State Work Done Repair Work Done © Type of Pump _ w Well Destruction ~❑ Well Diametertl _— Sealing Material {top 50') Depth_ .�-b J Filler Material IBelow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is n available within 200 feet.) V Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms F �� Character of soil to a depth of 3 feet: I Water table depth s SEPTIC TANK ❑ Type/Mfg; Capacity No. Compartments A 04 d Method of Disposal PKG. TREATMENT PLT. ❑ _ ' Distance to'nearesti Well Foundation Property Line 4# ' ys LEACHING LINE ❑ No. & Length.of lines Total length/size" I FILTER BED ❑ Distance to nearest: "WeilFoundation Property Line SEEPAGE PITS ❑ Depth —Size i' Number SUMPS ❑ Distance io nearest: Well Foundation' Property Line DISPOSAL PONDS ❑ 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 rules and regulations of the San Joaquin Local Health District. iperformance of the work for which this permit is issued, I shall not Home owner or licensed agent's signature certifies the following: "I certify that in the employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature I g.„ fY ersons subject to workman's compensa- i certifies the following: I certify that in th 1 performance of the work for which this permit is issued, I shall employ p 1 tion laws of California." r The applicant must call r all re aired spe tions. Complete drawing on rev rse side. r� i f _' Title:. ��l't Date: Signed FOR DEPARTM T USE ONLY D f Application Accepted by "v Date Area Pit or Grout Inspection by Date Fina! In ction by - Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 01 Manteca 823-7104 Tracy 6385 Applicant-Return all copies to: Envirorimental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 f CK RECEIVED BY DATE PERMIT"NO.]FEE NFOMAMOUNTI' AMOUNT REMITTED CASH —yEH 13-24(REV.101831 ` K EH 14-28