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W APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address A City Lot Size PM Owner's Name ddres /A' "� Phone L .� Contractor t Addres f� 4'tn.� � -?S,3,0 License No. � �62 Phone TYPE OF WELL/PUMP: NEW WELL ElWELL REPLACEMENT ElDESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK" SEWER LINES DISPOSAL FLD. PROP. LINE =¢ ��FOUNDAfi10N �""r'! " — GRICULTURE WECLT" C+TFIER WELL' - �� PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS XJndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by Repair Work Dane Type of Pump' State Work Done t H.P.ITA-T _ Well Destruction ❑ Well Diameter' Sealing Material (top 501 } 4 Depth ( Filler Material (Below 50') — TYPE OF SEPTIC WORK: NEW INSTALLATION-tl..-AEPAIRIADDITION LI DESTRUCTION i 1 (No septic system permitted if public sewer is S available within 200 feet.) Installation will serve: Residence Commercial- Other Number of living units: Number of bedrooms t Character of soil to a depth of 3 feet: .k _Water table depth SEPTIC TANK CIType/Mfg,I Capacity No. Compartments PKG.'-.TREATMENT PLT. ❑ Method of Disposal Distance to nearest: . Well Foundation Property Line .I LEACHING LINE O No. & Length of lines Total length/size FILTER BED 1-1Distancet6+nearest: Well Foundation Property Line I SEEPAGE PITS l 1 Depth 1 Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ w v 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 Di§trict. 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,I shall employ persons subject to workman's compensa- tion laws of California." _ f The applicant mu all for all re ulred inspections. Complete drawing on reverse side. ye Signed X Title: Date: OR DEPARTMENT USE ONLY ,Z Application Accepted by �r r Date Area �` Pit or Grout Inspection by ( Date Final Inspection by bate d Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1801 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i FEE AMOUNT DUE AMOUNT REMITTED .(CASH RECEIVED BY DATE PERMIT'NO. INFO t a b I �.EH13.24(REV.1irs5) S � EH 14-26