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APPLICATION FOR PERMIT E-S SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 .E. HAZEL T ON AVE., STOCKTON, CA `(} Telephone 112091 466-6781 two v-*�► � PERMIT EXPIRES 1 YEAR. FROM DATE ISSUED (Complete in,Triplicate) l 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 f 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.. r S72 J City Lot Size X/I ^'PM Job Address Ci I� Owner's Name dress Phone - `' ao , s � Contractor / A dress License ND. Phone TYPE WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT El DESTRUCTION L3 I % PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ' JI,",--:DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Q Industrial ❑ Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing Ll Domestic/Private El Gravel Pack ❑ Tracy Type of Casing Specifications ElPublic ElOther ElDelta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. - State Work Done ` Well Destruction ❑ Well Diameter F .v Sealing Material {top 50') �� r Depth Filler Material (Below 501 I ry i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ D S�R TION a septic system permitted if public sewer is � � �,x ayblehin 200 feet.) t Installation will serve: `Residence_ Commercial— Other—' - t Number of living units: 4Number of bedrooms , I Water table depth Character of soil to a-depth of.3 feet: r I No. Compartments SEPTIC TANK Type/Mfg Capacity i i „ a PKG. TREATMENT PLT. ❑ i \5 Method of Disposal Wl � f _ '•Distance to nearest: Well Foundation '' Property Line LEACHING LINE ElNo. & Length of lines Total length/size—., � FILTER BED ❑ Distance to nearest: Well Foundation Property Line ` 1 SEEPAGE PITS ElDepth i Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this applicationand 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 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." ; Theapplicant ust call foall require inspections. Complete drawing on reverse side. is Signed Title: &C Date: FOR DEPARTMENT USE ONLY � - -5�- Application,Accepted by Date Area Pit or lGrout Inspection by - Date Final Inspection by Date ' t 4 Additional Comments: ❑ Stk 466-6781 ElLodi 369-3621 ❑ Manteca -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 AMOUNT DUE AMOUNT REMITTED ,!CASH -` RECEIVED BY DATE PERMIT'NO. INFO 7j t + EH 13-244REV.t S-7—CAS EH 14.28 J