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Q - APPLICATION FOR PERMIT kSAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA .. Telephone (209) 466-67$1 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 constrDet 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 City Size Owner's Name � ' P '`k Phone 7-12 yob Contractor Address S4 A _ nee No. Phon TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT/L7 DESTRUCTION ❑ PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER ❑ 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 ❑ Industrial ❑ Open Bottom EJ Manteca d-o Well Excavation �! � i D Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack -L7 Tsacy-- Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal f Type of Grout ❑ Irrigation ___4 ox. Depth fy pastern Surface Seal Installed by ! Repair Work Done ❑ Type of Pump H.P. _ State Work bone_ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth -4 Filler Material ( elow 50') a TYPE OF SEPTIC,WORK: NEW INSTALLATION Il REPAIRJADDITION DESTRUCTION 13'(No septic system permitted if public sewer is T available within 200 feet.) Installation will serve: Reidence,, ComrsiePfial Number of living units , Number of bedrooms - , v—, I Character of soil to a depth of 3 feet: Water table depth'y `! SEPTIC TANK ❑ Type/Mfg 4 Capacity Compartments r� PKG. TREATMENT PLT. ❑ _ti s4,� •` Method of Disposal I Distance to nearest: Well Foundation .Property Line r LEACHING LINE Lir--No. & Length of lines Total length/size FILTER BED ❑ Distance to neo t: Well Foundation Property Line tel! SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation49 / Property Line DISPOSAL PONDS ❑ �- 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 J rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in tl'e performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subiect.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." The applicant.must II foo aWer�jviroe#-i pectin s. Complete drawing on revetse side. / f L§igned X Title: Date: r FOR DEPARTMENT USE ONLY `' Application Accepted by Date `Z Z A a // Pit Grout Inspection by y� to 2 jib FinanIJnspection by Oath y 4-, Additional Comments: l �� ! l ( [ �I 07 11 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 ti FEE AMOUNT DUE AMOUNT REMITTED CK INFO RECEIVED BY gN DATE PERMIT'NO. EH 13-24{REV. i x 51 EH 14-28 i