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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT + " " 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 i - ""PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the SanJoaquin 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. ` Job Address a Cityo;�� Lot Size PM F y � Owrier's Named'—Address "� `�4 f Phone s: Contractor's Nameicense No. / Phone 4,9 TYPE OF WELL/PUMFr. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 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 ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout SealType of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal-Installed"by Repair Work,Done Ll` Type of Pump H.P.,- State Work Done Wd11 Destruction ❑ Well Diameter Sealing Material (top 501 Depth r Filler Material /Be501) ry�k Pf OF SEPTIC WORK: NEW INSTAL A TION 11REPAIR/ADDITION DESTRUCTION 131No septic system permitted if public sewer is " 17'' i available within 200 feet.) - ` ,>F`Installation will serve: Residence Commercial_ Other T 3' rrd Number of living units: Number of bedrooms soil°to a depth of 3 feet: =` Water table depth ` SEPTIC TANK ❑ Type/Mfgt ""'�'"�� CapacityNo. Compartments PKG. TREATMENT PLT. ❑ + Method of Disposal Distance to nearest: We' _,.�oundation Property Line' LEACHING LINE No. & Length of lines Total length/size v FILTER BED Distance to nearest: Welirrr��V lundation Property Line r ''» p rtY SEEPAGE PITS Depth Size ii i Number f __ SUMPS ❑ Distance to nearest: Well .1.0 ( Foundation I TU.r Property Line 7-f _ DISPOSAL PONDS ❑ I hereby certify that I have prepared thisapplication and that the work will be done in accordance with San Joaquin county ordinances, state laws, and j 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 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 applicant ust or all required inspect- Complete draw- on re se side. 1 f Signed X le: Date: C 1 " =DYKAN, TMENT USE ONLYApplication Accepted byData r3" i Area Pit or Grout Inspection by 1�1. • ate 5-3- y Final Inspection by 47A S n,..,._N-Date i� Additional Comments: I 1 ❑ Stk 466-6781 ❑ Lodi 369-3521 ❑ Manteca 823-7104 ❑ Tracy 835-M Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 FEE 4 CK 4 INFO AMOUNT DUE 1 AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"N0. 1111 + EH 13-241REy.10/631 EH W26