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APPLICATION FOR PERMIT ^ SAN JOAQUIN LOCAL HEALTH DISTRICT i 1601 E. HAZE T ON AVE., STOCKTON, CA l.! VnP 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 Addras`s a City 5�?tmM_at Size PM Owner's Name _ 5��y��r� Address /, /,/• Phone CentraLtOr Address 9/r2?L9 License No.ATg//, Phone TYPE OE WELL./PU_MP: NEW WELL 0 _ WELL REPLACEMENT ❑ DESTRUCTION_❑ 1 PUMP„INSTALLATION)0 fEP4fi4g HNTSY�T, M REPAIR 1 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ' � aISPOSAL FLD. PROP. LINE I ..._._....._._._.FOIJND_AT-ION AGRICULTURE WELL. -...-.. ( T,HEH_WELL. _PITS/.SUMPS INTENDED USE TYPE OF WELL r PROBLEM AREA CONSTRUCTION SPECIFICATIONS I ❑ Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation ! Dia. of Wel! Casing t i i VDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Fl Public ❑ Other -FI-Delta Depth of Grout Seal Type of Grout I I Irrigation __.Approx. Depth fl I"Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump I H.P. ! State:Work Done Well Destruction ❑ Well Diameter f' Sealing Material (top 50') 1 Depth Filler Material(Below 50') l i TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION LI DESTRUCTION { ]JNo septic system permitted if public sewer is u ( i available within 200 feet.I Installation will serve: Residence_�Commel'cial- Ottie"r' Number of living units: Numbg5bf bedrooms x �t Character of soil to a depth of 3 feet: 1 P Water table depth ' SEPTIC TANK ❑ Type/Mfg i Capacity-, No. Compartments PKG, TREATMENT PLT. ❑ A i i Method`of_pisposal. . - Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ No. & Length of'lines Total length/size i FILTER BED ❑ Distance to nearest: Well Foundation (Property Line r 9 r i i 1 SEEPAGE PITS I I Depth Size Numbei SUMPS Cl Distance to nearest: Well Foundation Property Line r 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. 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 shalt 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." The applicant m r !I requir tions. Complete drawing on re r e�'�e•. Of Signed X Title: Date: 74 61X'7 w FOR DEPARTMENT USE ONLY Application Accepted by Date �r -� � Area /� Pit or Grout Inspect' y Date Final Inspection by Date Additional Comments:. ❑ 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 INFO AMOUNT DUE AMOUNT R MITTED CASH CK 11 RECEIVED BY DATE PERMIT-NO. ♦ EH 13-24 1REV.1/9 51 EH 14-26 GY J"