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I ' APPLICATION FOR PERMIT € SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. �j r g 4 Job Address S�� / t� �z �? r - City C +E1lLot Size J �„ U Or,,._PM Owner's Nama +Address Phone o� }� Contractor { Address T License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER D ; DISTANCE TO NEAREST:SEPf1C TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION. AGRICULTURE WELL OTHER WELL PITSlSUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia- of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 17 Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout --- I i Irrigation __Approxi:Depth I I Eastern Surface Seal Installed by 1 - Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501) _ Depth FillerIVfaterial /Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION -If'] REPAIR/ADDITIOqX DESTRUCTION I I (No septic system permitted if public sewer is � � available within 200 feet.) Installation will serve: Residence. Commercial Other Number of living units: _,IL— Number of be rooms J I Character of soil to a depth of 3 feet:. Water table depth N SEPTIC TANK 7< Type/Mfg Capacity No: Compartments oZ PKG. TREATMENT PLT. ❑ ) ffs Method of Disposal Distance to nearest: Well ' U Q Foundation e Property Line 5dQ LEACHING LINE No. & Length of lines Total length/size f _ FILTER BED ❑ Distance to nearest: Well Foundation Property Line y SEEPAGE PITS F1 Depth f Size _-3 Number - SUMPS )4 Distance to nearest: Well ' Fouridatio6 1 1)�D. 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 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 folio : "I certify that in the performance of the work for which this permit is issued;-1 shall employpersons subject to workman's compensa il tion laws of Cal or ia." i. I The applicant u call for all re nspectionsComplete drawing on reverse side. I Signed X ) C! Title:. - r . , 4 Date: FO4R DEPARTMENT USE ONLY Application Accepted by 'Date 'Z ` Area f .. , ( f Pit or Grout Inspection by Date } Final Inspection by S Date C Additional Comments: �� I O Stk 466-6781 LI Lodi 369-3621 © Manteca 823-7104 ❑ Tracy 835-6385 Appl-icant -.Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUE S �rAMOUNT REMITTED CASH RECEIVED BY DATE I PERMIT'No. r + EH 13-241REV.t/H51 r �jy EH 14.26