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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED T Y 4 (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.'. s^ City Lot Size � PM Job Address F � �L Address 1,`1� "`� Phone `s Owner's Name �-1 Contractoral"varQ s Address (n L Uo U r —I icense No � Phon es` TYPE OF WELL/PUMP: NEW WELL LJWELL'REPLACEMENT'❑.:� _j DESTRUCTION LJ N —PUMP INSTALLATION O �- •• : ._..SYSTEM REPAIR '12 — -: ,-OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK - -SEWER-LINES -DISPOSAL FLD �--Y-° PROP: UMP S FOUNDATION AGRICULTURE WELL OTHER WELL— INTENDED INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom [IManteca Dia. of Well Excavation Dia. of Well Casing 9 7-1 Domestic/Private F1 Gravel Pack El Tracy Type of Casing Specifications - ❑ Public C1 Other C1 Delta 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 Sealing Material (top 50') - A Depth Filler Material (Below 501 UA TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ Mo septic system permitted if public sewer is ud available within 200 feet.) j` Installation will serve: Residence Commercial Other Number of living units;J Number of bedrooms -_ Character of soil to a depth of 3 feet: � ��' " �t—{� ;Water table-depth- SEPTIC TANK j ❑ Type/Mfg Capacity No. Compartments M PKG. TREATMENT PLT. ❑ a _ Method of Disposal Distance to nearest: Well Foundation Property Line 'f t LEACHING LINE� <—No:& Length of lines � �� Total lengthlsize FILTER BED - - ❑ -Distbnce to nearest:- Well--! --Foundation Property Line SEEPAGE PITS Imo' Depths 1 Size ��r Number ti �.r -Foundation.: -, - ,r -property-,Line T' T - SUMPS ❑ Distance to nearest: •� Well- �--- _. • 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,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 rson in such manner as to-become-subject,to workman's'�compensation laws of California."Contractor's hiring or sub-contracting signature certifies tf, fol/ Ing: "l certify that in the performance of the work for whibh.this permit is;issued,I shall employ persons subject to workman's compensa- tion laws f Calif nia." w The applic nt us r all required inspections. Complete drawing on'verse side.r� — Title: ti.. � .. Date: Signed FOR DEPARTMENT USE ONLY ° Date Area l Application Accepted by -f_: �(]'''� Pit or Grout Inspection by ' =ate; = VFinal Inspection by Date i 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 AMOUNT DUE AMOUNT REMITTED194 RECEIVED BY DATE PERMIT'NO. INFO � + EH 13.24{REV.t $$) '`! b�. cs o 33`� / •-� C_, EH 1428 t