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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA i Telephone (209) 466-6781 it PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) f Application is hereby made to the San Joaquin Local Health District for a pedescribed. This application is permit to construct and/or install the work herein made a 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. l �I �piti City �-� 2) Lot Size 7- t �5AC PM Job Address t e Address Phone k Owner's Name r t WQ License No,�,?[�� th4 Contractor �L ' u Address TYPE OF WELL/PUMP: NEW WELL WAlK,EPLACEMENT DESTRUCTION ❑ 'PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER El DISTANCE TO NEAREST: SEPTIC.TANK 1-SD�,., SEWER LINES DISPOSAL FLO. PROP. LINE 1�. = �f FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing if 11 Industrial ❑ Open Bottom C3 Manteca Dia. of Well Excavation Type of Casing Specific�Grout ns Domestic/Private Pk Gravel Pack ❑ Tracy YP Type of ["1 Public F1 Other. 1`7 Delta Depth of Grout Seal -~ a- '-�'Approx..Depth l I Eastern Suit ce Seal Installed by I ! Irrigation f� / H p State Work Done — Repair Work Done [I Type of Pump � t d-.: Ub Well Destruction ❑ Well Diameter.1 A11-- . Sealing Material (top 501 Depth z Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION I I aNailabeti systemithin rented if public sewer is Installation will serve:. Residence_ Commercial_ Other Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: SEPTIC TANK ❑ y Type/Mfg Capacity No. Compartments Method of Disposal PKG. TREATMENT PLT. ❑ Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED 17 Distance to nearest: . Well Foundation Property Line SEEPAGE PITS I 1 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, 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, l shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's or to workmanlscompensa- signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ psubject tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. ��T _ Date: Signed X Title:�-�'�- FOR DEPARTMENT USE ONLY Date Area G Application Accepted by I Pit or Grout Inspection by Date Final Inspection by ate C, Additional Comments: < fzz ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-638 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE CIC RECEIVED 9Y DATE PERMIT-N0. AMOUNT DUE AMOUNT REMITTED CASH INFO j /} � �kk +.EH-13-241r1EVi 1 -.2 - EH 14-28