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APPLICATION FOR PERMIT l SAN JOAQUIN LOCAL HEALTH DISTRICT 1601. E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES I YEAR FROM DATE ISSUED l " (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 j Local Health District. Job Address / City / GY Lot Size PM Owner's Name . 1 AddressZ ' ^ �7' Phone �-S7 ContractorlG1hI[� —Addresses _ License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIO PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK .5 SEWER LINES DISPOSAL FLD._&-1 — PROP. LINE FOUNDATION _ AGRICULTURE WELL OTHER WELL PITS/SUMPS [w INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS * Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing rSpecifications ❑ Domestic/Private G Gravel Pack G Tracy Type of Casing 1-1 Public C1 Other I Cl Della Depth of Grout Seal Type of Grout I I IrrKJation Approxi, Depth I I Eastern Surface Seal Installed by - Repair Work Done C) Type of Pump H.P. State Work Done -- Well Destruction Well Diameter _ / Sealing Material (top 50'1 Depth f Filler Material (Below 50 vA[r��T� ` TYPE OF SEPTIC WORK: NEW INSTALLATION 1J REPAIR/ADDITION ( I DESTRUCTION I I (No septic system permitted if public sewer is t available within 200 feet.) Installation will serve: Residence_• Commercial Other�..__ ~ j Number of living units: Number of bedrooms y Character of soil to a depth o1 3 feet _ Water table depth I SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 1Method of Disposal Distance to nearest: Well Foundation__ Property Line LEACHING LINE ❑ No. 8 Length of lines Total.length/size_. FILTER BED U Distance to nearest: . Well Foundation Property Line — i -- SEEPAGE PITS I I Depth `_ Size — Number SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I 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. 11 Home owner or licensed agent's signature certifies the following: "I certify the rk for which this permit is issued, I shall not t in the performance of the wo 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." I The applicant must or l r red inspections. Complete drawing on reverse ' e. -- r / ) Ja f Signed Title: Date: ` { FOR DEPARTMENT USE ONLY i Application Accepted by `-- Date 7C? ' Area Pit or t Inspection by Date Final Inspection b Date 6 AddivonalrrlC W Uk u ��✓ t ❑ Stk 466-6781 ❑ Lodi 369.3621 Cl Manteca 823-7104 L.1 Tracy 835-6385 Applicant • Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk-, CA 95.201 (� f N�lG�F`J— ACGo�c�[� � f. A �c.s•.� t �// waS gcS�rl�fO� /ti (SQ�'•�u�cj4e! SrtT ��o/d ca 11/•tq[) 1 ! FEE [jAM!jOUNT DUE v AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO /O f a EM 13-z41REV.I/H5) EH 14-26 -P