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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.;_STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED l (Complete in Triplicate) f " 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 C Job Address 'City Lot Size PM . Owner's Name Address _ Phone ContractorAddress Q /A "d ` N`^'�icense No"E �585 Phon TYPE OF WELL/PUMP: 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/I i ate ❑ Gravel Pack i ❑ Tracy Type of Casing Specifications . ❑ Public IDOther L1Delta Depth of Grout Seal Type of Grout �4 ❑ Irrigation , n=--�-Approx:-De tt ❑-Ea-terfi---I Surface Seal Installed by Repair Work Done ❑ 'T t 1 y p Type of Pump H.P. Re _ L'. State Work Done_ Well Destruction ❑ Well Diameter F Sealing Material (top 50') v V t Depth "` """'"'" RFiller 11Aaterial"(Be[. TYPE OF SEPTI.WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ {No septic system permitted if public sewer is G r t r i .availah vSithin'200feet.I Installation will serve: R�(sid§ence 'Commercial Other¢ �, Number of living units: �� Number of bedrooms ID Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK &'Type/MfgOWea-6�`Gl[G '= Capacityl� No. Compartments AAA77 PKG. TREATMENT PLT. ❑ Method of Disposal I Distance to nearest: Well Foundation 'Property Line , LEACHING LINE _No..&`Length of lines-£ "? Total length—/size 40 FILTER BED ❑ Distance to nearest: Well a Foundation Property Line SEEPAGE PITS ❑ Depth Wit, Size _ Number y SUMPS. ❑ ,"Distance to nearest: Well + Foundation Property Line ]1 DISPOSAL PONDS ❑ I 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. . 'n t . --fl • .1Home owner or licensed agent's signature certifies the followings"I certify that in the performance of the work for which this permit is issued, i shall not employ any person in such mariner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature R– _..certifies tIlowing:.'I certifyvthat in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of C f or na. . - The.appI an st call for uired inspections. Complete drawing /o�n�ryy r�se_side //' Signed X Title: r�LV�C, Date: -/ � FOR DEPARTMENT USE ONLY Application Accepted by ' aeti• - � Area "Pit or Grout Ins pection by Date Final Inspection on b by Date � I Additional Comments: ❑ Stk 466-6781 El Lodi ,369-3621 } Manteca 823-7104 ❑ Tracy 835-6385 F Applicant- Return all copies to: Environmental Heafth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I -3 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. tt + EH 13-24(REV. -7-:10 EH 14-28