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APPLICATION FOR PERMIT SAN JOAO.UIN,LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 .0 h e 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. G, "- f // r L3 / City r ` -Lot Size 7s .6 /SO PM Job Address � - 3 Owner's Name' ` "' Address Phone Contractor Address License No. Phone_ TYPE-6F—WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r }� PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ �!" DISTANCE TO NEAREST: SEPTIC TSE11K SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISU,MPS INTENDED USE TYPE OF WELL PROBLE CONSTRUCTION SPECIFICATIONS pia. of Well Casing E] Industrial ❑ Open Bottom C1Manteca r i Well Excavation T e of Ca ' Specifications ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy YP H p State Work Do Type of Grout 11 Public ❑ Other E] Delta of Grout Seal r. 9 ❑ Irrigation _--Approx. Depth ❑ East Surface Seal Installed by Repair Work Done [IType of Pump Well Destruction ❑ Well Diameter Sealing Material [top 50'1 Depth -- -x Filler Material (Below 501 erm TYPE OF SEPTIC WORK: NEW INSTALLATION Ll REPAIR/ADDITION ❑ DESTRUCTION , (Noem avaseptic sy t 20U feetitted if public sewer is Installation will serve`. Residence— Commercial, Other Q, Number�of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: SEPTIC TANK LD Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. EDMethod of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE El No. length/size No. & Length of lines - I FILTER BED ❑ Distance to nearest: Well Foundation Property Line I' SEEPAGE PITS ❑ Depth Size Number y SUMPS ❑ Distance to nearest: Well Foundation Property Line I DISPOSAL PONDS ❑ 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." ploy ceo�nshiring subject t wosub-contracting compensa- certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ p 1 tion laws of California." The a plicant uAt call for alrequired ' S tions- Complete drawing on reverse side. Title: -x C`-i�� Date: Signed'X FOR DEPARTMENT USE ONLY 7 Date J �� 1.4 7 Area Application Accepted by Date Final Inspectio y Date Pit or Grout Inspection by 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 CK RECEIVED BY GATE PERMIT•NO. AMOUNT DUE. AMOUNT REMITTED INFO + EH 13-241REV.1/K5) EH 14-26