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APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES (YEAR FROM DATE ISSUED k (Complete in Triplicate) E 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 I made in compliance with San Joaquin County Ordinanc&No.549 for sewage or No. 1862 for welUpump and the Rules and Regulations of the San Joaquin 1 k Local Health District. �. �L' ' f� _ ` l �3�P�dLZf1 - City ^z Lot Size �/ �gC_/ PM Job Address T ll k Owner's Name Address _ �F _ Phone ; Contractor '~ &1-(55JC Address A474y- License No. 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 FOdNDAT10N AGRICULTURE WELL OTHER WELL PITS/SUMPS 4 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 F-1 Public ❑ Other n Delta Es Depth of Grout Seal Type of Grout - 4 I I Irrigation —.-Approx. Depth 1 1 Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump _ H.P State Work Done Well Destruction ❑ Well Diameter Sealing Materiall(top 501 Filler Material (Below 50') -- Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIWADDITIONX DESTRUCTION I I (No septic system permitted if public sewer is r available within 200 feet.) Installation will serve: Residence Commercial, ther % Number of living units: 4- Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg + Capacity— No. Compartments PKG. TREATMENT PLT. ❑ } w t !#Y 1r Method of Disposal %Distance to nearest: Well Foundation, Property tine-' ' i k F J LEACHING LINE � No. & Length'of lines T_ Total length/size��y ,,.. FILTER BED ❑ Distance to nearest: Well�= Foundation'y-"S��`�- Property Line �1 k SEEPAGE PITS I I Depth Size _ Number } SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 '#� hereby certify that 1 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. t 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, l 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 1 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." j The applicant must tail for required inspections. Complete drawing on reverse4i$e� .. I Signed X Title" Date: _ F, PART �TUSEONLY Application Accepted b Date Ar / Pit or Grout Inspection by k Date Final Inspection by Oats/ 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.D. Box 2009, Stk., CA 95201 Y FEE AMOUNT DUE AMOUNT REMITTED CK" RECEIVED 6Y DATE PERMIT"NO. r INFO 1 fnt� CASH u/� a .EH 13-241REV,r�i8sl l�.�".lf'F ` .1-7 - .-.. `�. 111 EH 14-28' '