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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT t 1601 E. HAZE 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. Joh Address 2 SS9 y � City LSlze PM 16 Owner's Name * •"• Ai]dress'-- Phone? _ License NonLq,/`�L7Phone �v •� Contractor rens TYPE OF WELL/PUMP: NEW WELL ❑ v WELL REPLACEMENT ❑ DESTRUCTION ❑ r PUMP INSTALLATION ❑ ' u SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES , DISPOSAL FLD. PROP. LINE FOUNDATION' AGRICULTURE.WELL`- OTHER WELL PITS/SUMPS INTENDED 115E TYPE OF PROBLEM AREA CONSTRUCTION SPECIFICATIONS Y ❑ Endustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavatit5n Dia. of Well Casing -❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f ❑ Public '-01 ❑ Other ll'tDelta Depth of Grout Seal Type of Grout .' '• I I.Irrigation .-Approx. Depth I I Eastern tIN.� i Surface Seal Installed by - Repair Work Done ❑ Type of Pump %�H?P. State 1Nork Done_ Well Destruction ❑ Well Diameter Sealing Mater al (top 501 d i ^v Depth Filler Material (Below 50'•) Lj TYPE OF SEPTIC WORK: NEW INSTACL-ATION i*T REPAIR/ADDITION 4:1, DESTRUCTION l I (No"septic system permitted if public sewer is+ V r available within 200 feet.) ,C Installation will serve:"'Residence��Commercial— Other , >F, `•.� Number of livingunits: Number of-bedroom R ,y Character of soil to a depth of 3 feet:; , - f t Water dab)d depth •* l SEPTIC TANK ❑ Type/Mfg '� Capacity a� Nb. Comparimen[s`� PKG. TREATMENT PET. ❑ f 7 Iii t oimoi JIMethod ofDisposal Distance to nearest:* Well Foundation .__ .._..._ Property Line i n LEACHING LINE ❑ No. &Length`�61` lines 1j S Total length/size �,.., /�•�y � FILTER BED ❑ Distance to nearest: Well Foundation Z Property Line ti141 SEEPAGE PITS l l Depth _ate , Sire Number 01 3 SUMPS I-1 Distance to nearest: WellFoundation Property Line DISPOSAL PONDS .n I hereby certify that I have prepared this apptication 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." ; I , The applicant must call for all re 'red inspections. Complete drawing on reverse side., Signed X Title: Date: ��FOR D NT USE ONLY �Application Accepted by Date Area - Pi or Grout Inspection by' , Da / Final Inspection by� �� te Date fV Additional Comments: , ❑,Stk 466-6781 ❑ Lodi 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., CA 95201 tFEE OUNT DUE AMOUNT REMITTED C C KSH RECEIVED BY DATE # PERMIT'NO. INFO /)mJ r EH 13-24(REV.IIK51 EH 14.26