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_�. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA ,tea Lr.� i -A, Telephone 12091 466-6781 / PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Nab, (Complete in Triplicate) 0Q. a Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein describ d. 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. 2 / Job Address J /+ �� Lf .,City t Size AM Owner's Name � ()� J Phone` r- Contractor Address 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 FLO. PROP. LINE FOUNDATION :AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS . O` ❑ Industrial LJ Open Bottom LJManteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications s (I Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout •— I Irrigation __.Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done El Type of Pump H.P. State Work Done'FN- ' Weil Destruction ❑ Well Diameter ;� Sealing Materia! (top 501 (314 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTIO1No septic system permitted if public sewer is available within 200 feet.) \ N Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms 1 Character of soil to a depth of 3 feet: Water table depth i SEPTIC TANK e� ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal,. x i . Distance to nearest: Well Foundation Property Line a LEACHING LINE ❑ ',No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line _t t t SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation 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, an 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 s employ ariy 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." The apptica st call for all required coons. G pl to drawing on reverse side. Signed X - Title: - Date: FO DEPARTMENT USE ONLY {� Application Accepted by Date ti" �� Area I i Pit or Grout Inspection by Date Final Inspection by �"— Data Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 E7 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 AUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT'NO. INFO + EH 13-24 1REV.I/11 51 �� 3 �/ f EH 14-28 +6�