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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT . • 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 i PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) I 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. x Job Address 7 City—c;- Lk Lot Size PM Owner's Name Address Phone Contractor I t- CF' g dAddress 3 icense No. Phone 91g TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ l PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER EJ DISTANCE TO NEAREST: SEPTIC TANK"' SEWER LINES DISPOSAL FLO. 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 El Domestic/Private ElGravel rack ❑ Tracy Type of Casing Specifications 4. FI Public t ❑ Other F1 Delta Depth of'Grout Seal Type of Grout I I Irrigation' I- r- _Approx. Depth l I Eastern < ; Surface Seal Installed by _ Repair Work Done ❑ Type of,Pump H.P. State Work Done T Well Destruction I Weil Diameter, Sealing Material Itop 501 r• Depth— `..- _Filler Material 1Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION X_ 9£STRUCTION I I (No septic system permitted if public sewer is P available within 200 feet.) i Installation will serve: Residencet-�bmmercial_�Other Number of living units: —I— Number of bedrooms iCharacter of soil to a depth of 3 feet: A b o L 1�1:4 a1^�._Water table depth SEPTIC TANK ❑ Type/Mfg Q o 1 _r Capacity. No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Ik Distance to nearest: Well `.�bQ Foundation Property Line I '� LEACHING LINE W_---ftto. & Length of lines 0 Total length/size FILTER BED f El Distance to nearest: Well r Foundation-_ Property Line SEEPAGE PITS IU--Depth. Size 7a:, Number SUMPS Ll Distance to nearest: Well e-kODf Foundation (. -- Property Line DISPOSAL PONDS L1 ! 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 s 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."Contractors hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued.,f shall employ persons subject to workman's compensa- t1'o�t`fear of Califo, The epplico_ st call fo all r uire Hsps i �sp�lol. rawing o verse sid - Signe Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by 1 r Date — 1 Area Pit Grout Inspection by / Date vVr Final Inspection by ' Oats r Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manfeca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.r CA 95.201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK 4 RECEIVED BY DATE PERMIT NO. + EH 1324 1REV.i/m 51 _ EK 14-28