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c APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT - 1601 E. HAZELTON AVE., STOCKTON, CA x Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is heieby 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. C Job Address Cityy� --- Lot Size PM Owner's Name a s Im Address � tac� t �[�tlo��!_ Phone Contractor L f's r 1l L f- Address 100 License No.a:Z-S--5 Fr?r 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications (`l Public F] Other F1Delta Depth of Grout Seal Type of Grout ` I � i I I Irrigation _Approx. Depth l I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 i Depth Filler Material (Below 50') -- TYPE OF SEPTIC WORK: NEW INSTALLATION I.1 REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_____ Commercial_ Other ( f Number of living units: I Number of bedrooms a '� 1 Character of soil to a depth of 3 feet: _sq dd(t,pzn __Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal [ Distance to nearest: Well Foundation Property Line IJ LEACHING LINE VNo. & Length of lines ) — 97) Total length/size 90 FILTER BED ❑ Distance to nearest: Well S70 Foundation _�.� Property Line— SEEPAGE PITS l I Depth Size r _ Number + SUMPS 0 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 i 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." Contractors hiring or sub-contracting signature certifies the fotlowing: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workma s compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. C �• l Signed X Title: .9/1 1 date: o � r a FOR DEPA MENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection b 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, S1k., CA 95201 R FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMtT'NO. INFO CASH �.EH13-24(REV.t/Ks7 EH 1428