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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephohe (209) 466-6781 PERMIT EXPIRES TYEAR 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. /-� �,, 'l y/J Job Address `'�IR? �. /LGi. City r Lot Size PM Owners Name V Address VJ r Phone Contract f Addressp0_96X n-7 otLicense iVo Zzte Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ 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 ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ID Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout i I Irrigation - — Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ C7 Well Destruction ❑ Well Diameter Sealing Material (top 50') - Depth Material (Below 501 _ 6 TYPE OF SEPTIC WORK: NEW INSTALLATION f 1REPAIR! DDlTIDN DESTRUCTION l I f aseptic.system permitted if public sewer is t ll ilable within 200 feet.) Installation will serve: Residence_ Commercial Oth Number of living units: Number of drooms _1 Character of soil to a depth of 3 feet: Water table depth SEPTIC-TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal l Distance to nearest: Well Foundation Property Line—. ----. LEACHING LINE "_1KNo. & Length of lines Total length/size X " r FILTER BED ❑ Distance to nearest: Well 1jQ0 r Foundation 10 Property Line SEEPAGE PITS 11 Depth Size `a Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ r E� 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 t 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 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, 1 shall employ parsons subject to workman's compensa- tion laws of California." The applica ust call fo 11 r quiro inspections. Complete drawing on reverselip� � Signed X Tit(e: t Date: FOR DEPARTMENT USE ONLY A Application Acce"pled by 'r` Date6— `"1� � Area�- G Pit or Grout Inspection by. Data Final Inspection b,:' Additional Comments: ❑ Silk 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 f INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE PERtMIT'NO. +.EH 13-24(REV.ti i H 5) jl yr d U LCI EH 14-213 [