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i I ' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 . - • " ` r 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. t^ y -GotIVN � Ci '�. `Lot SSed ! M O�� Job Address -7 e- city �6 I Owner's Name�� T �� "�— Address �%y` -_ �1= Phone �d i Contractor Ang, Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT-❑ DESTRUCTION ❑ I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ` DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL_'�"�OTHER WELL-L—_=_ _ - PITS-/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t . ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation s `' Dia. of Well Casing r ❑ Domestic/Private ',�` ❑ Gra4_el Pack`., ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ti" ❑ Delta Depth of Grout Seal Type of Grout i ❑ Irrigation 3 —Approx. Depth ❑ Eastern Surface Seal.,lnstalled by - H.P. State Wl �k Done. I Repair Work-Done. ❑ Type of Pump r ' l Well Destruction' ❑ Well Diameter ' l Sealing Material (top 50') Depth Filler Material (Below 50').„ - TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is f available within 200 feet.) Installation will serve: Residence_ Commercial -Other S Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: f Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENTPLS. ❑ Method of Disposal ' \ 'Distance,,to nearest: Well Foundation Property tine - -� - - j LEACHING LINE , ❑ No. &Length of lines € I Total length/size FILTER BED ` ❑ _D'r+stance to nearest: Well Foundation Property Line �� rF f SEEPAGE PITS ❑ Depth Size ' Number SUMPS ❑ Distance to nearest: Well Foundation ~�r`tY Property Line ' € DISPOSAL PONDS ❑ § ' t 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. i m # 1 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-coritracting signature r _ certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall employ persons subiect to workman's compensa- tion laws of Calif&h1 { The applicant mustc for all r spections. Complete drawing on reverse side. : Si ned Title: ` • Date 9 FOR,DEPARTMENT USE ONLY Application Acc d by Date Area ea l Pit or Grout Inspection by Date. _ Final Inspection by Date i Additional Comments: ❑ Stk 466-6781 ❑ Lodi V 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., A 95201 FEE AMOUNT DUE AMOUNT REMITTED A RECEIVED BY DATE "IT"INFO+ EH 13-241AEV.tied EH 1426