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APPLICATION,FOR PERMIT A UeJi- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON.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 well/pump and the Rules and Regulations of the San Joaquin I Local Health District. ,1 Job Address - .,K City 1 Lot Size v E PM r Owner's Name � � Vv� Address �' Phone � ... License No q 10D _ Phone !f7 i �C Contractor's Name 3 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION El PUMP INSTALLATION ❑ SYSTEM REPAIR X OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK /E,L' SEWER LINES DISPOSAL FLD. PROP. LINE — t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I¢ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing XDomestic/Private ElGravel Pack }❑ Tracy Type of Casing Specifications C3Public 11Other ❑ Delta Depth of Grout Seal Type of Grout D Irrigation ---Approx. Depth ❑ Eastern Su ace Seal Installed by Repair Work Done )91 Type of Pump:_ H.P. �_ f State Work'Done Well Destruction ❑ Well Diameter �f j -- Sealing`Material (top 501 Depth } Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION'❑ REPAIR/ADDITION ❑ DESTRUCTION'[] (Not septic system permitted if public sewer is 6 I R� q av dable within 200 feet.) Installation will serve: s Residence Commercial Other Number of living units:` Number of bedrooms ' f ° ' r _Water table depth Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg I i t _ Capacity No. Compartments I PKG. TREATMENT PLT. ❑ i. - ,. Method of Disposal Distance to nearest:k Well Foundation r` Property Line LEACHING LINE ElNo. & Length of I nese ' s' Totaf length/size r FILTER BED ❑ Distance to nearest:"I—Well Foundation Property Line F SEEPAGE PITS ❑ Depth Size Number + SUMPS ❑ Distance to nearest- ,Well Foundation Property Line I� . 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, 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." ' fl i The applicant sl ca I for I r it inspections. Complete drawing on rev se side. (/ s .C C — r Data. `r0 Signed Title: OR DEPARTMENT USE ONLY (� Date �a Application Accepted by Area;_FJ R Date Final Inspection by — � $ jPit or Grout Inspection by 1 Additional Comments: ❑ Stk 466-6781 E3Lodi 369-3621 C71Manteca 823-7104 ❑ Tracy 635-6385 t0 # Applicant-Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk:R ` 9520 nt X V L FEE AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE sw n5 PERMIT" . INFO +EH 1324(REV.14!931 3 S �,� I �� (p FS O-3 { EH 14-26