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F1 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRtL;T 1601 E. HAZEL T ON AVE., STOCKTON, CA Ft Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I (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 welUpump and the Rules and Regulations of the San Joaquin Local Health District. + Job Address (� ? �. �� ,4,'S, ��.�� City Lot Size / � PM Owner's Name c`T a /IDS ? Address Phone Fs Contractor 1� -�� Address License No ` Phone I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR C1 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r 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 Cl Tracy Type of Casing Specifications M Public Cl Other H Delta Depth of Grout Seal Type of Grout f ¢ I 1 Irrigation --Approx. Depth I I Eastern Surface Seal Installed by I Repair Work Done 11Type of Pump H.P. State Work Done ` Well Destruction ❑ Wel! Diameter Sealing Material (top 50'1 \ Ft' Depth Filler Material 113elow 501 T' TYPE OF SEPTIC WORK: NEW INSTALLATIONREPAIRlADDITION i I DESTRUCTION I I INo septic system permitted if public sewer is 5 available within 200 feet.) Installation will serve: Residence 1< Commercial— Other �\ Number of living units: L Number of bedrooms 0 Character of soil to a depth of 3 feet: 4 VV 1340 Water table depth SEPTIC TKNIC " ❑ ,Type/Mig - Capacity No. Compartments 9 PKC. TREATMENT PLT. ❑ " . xFV Method of Disposall– Distance to nearest: Well- klub Foundation' -""-�(r Property.Line .. r` LEACHING LINE No. & Length of lines -�` Toottal'tength/size d *FILTER BED ❑ Distance to nearest: Well 0 d� Foundation Property Line t I _ SEEPAGE PITS I'I Depth Size Number SUMPS L7 Distance to nearest: Well Foundation Property Line I DISPOSAL PONDS ❑ ; I 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, 1 shalt not employ any person in such manner as to become subject to workman's compensation taws 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." i The applicant must call Zorallquire inspectio Complete drawing on reverse side. Signed r Title: Date: - F#k OLIPARTMENT USE ONLY Application Accepted by Date r Area Ir/ Pit or Grout Inspection by Date Final Inspection by Date/ Additional Comments: ' ❑ Stk 466-6781 EJ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009,.Stk., CA 95201 r FEE AMOUNT DUE.. AMOUNT REMITTED CK RECEIVED 6Y DATE L INFO - . .. . C H PERMIT ND. �+ ER13-24(REV.II115) EH 14-29