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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT t 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (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 wail/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address City Lot Size PM owner's Name L Address w Phone el -II '2 16 V(�'hone' License No. Contractor _kl�C Address v� kjTYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Q DESTRUCTION ❑ Ea PUMP INSTALLATION ❑ SYSTEM REPAIR Er OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS E! INTENDED USE TYPE OF WELL PROBLEM`AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ ,Open Bottom C] Manteca Dia. of Well Excavation Dia. of Well Casing .i Xbomestic'/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications j�M Public Cl Other Cl Delta Depth of Grout Seal Type of Grout I I irrigation --Approx. Depth /IpI Eastern Surf a a Seal Installed by - EJRepair Work Done '9 Type of Pump 5s'aiQt= H.P. State Work Done l i(Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material ISelow 501 s . TYPE OF SEPTIC WORK: NEW INSTALLATION 1.7 REPAIRIADDITION l 1 DESTRUCTION l 1 (No septic system permitted it public sewer is available within 200 feet.] kl I : Installation will serve: Residence_ Commercial_ Other s Number of living units: Number of bedrooms ' Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK D Type/Mfg Capacity No. Compartments n PKG. TREATMENT PLT.❑ Method of Disposal CP 'Distance to nearest: Well Foundation Property Line i i LEACHING LINE ❑ ; No. A Length of lines Total length/size FILTER BED ❑', Distance-to nearest: Well Foundation Property Line SEEPAGE PITS I 0i Depth Size Number SUMPS L-01i Distance to nearest: Well Foundation Property Line . 3 p'i DISPOSAL PONDS 0 it - E 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 Diltrict. 7 , 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 i employ any 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." it The appl' mu all for all required :tixonComKdrawing on reverse side. �N1 Signed X Title: Date: l� ' FOR DEPARTMENT USE ONLY `il Application Accepted by Date - Area r I Pit or Grout Inspection by l Date Final Inspection by Date Additional Comments: 1-1 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ElTracy 835-6385 i Applicant - Return ail copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 .1 FEE i f INFO AMOUNT DUE AMOUNT REMITTED CASH CK It RECEIVED BY DATE PERMIT'NO. i r-EH 13-241REV.vxs} If EH 14-28 F ti: _