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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i (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 wall/pump and the Rules and Regulations of the San Joaquin Local Health District. � Job Address JJa� 'Wer, 1' �` City �� Lot Size PM Y60e , , ,� Owner's Name Address Phone Contractor �G�I�VlI/� Address G �le � License fyo. x Phone �� S TYPE OF WELL/PUMP: NEW WELL ❑ W LL REPLACEMENT 11 DESTRUCTION ❑ ff PUMP INSTALLATION El SYSTEM REPAIR 17 OTHER fVQ64ec�1f cd_&r1hrL 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/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications r [`l Public )(Other ~n Delta Depth of Grout Seal Type of Grout I I irrigation /51 pprox. Depth l-I Eastern •a Surface Seal Installed by A64,Z Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 it I Depth Filler Material (Below 501 2 TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION I I DESTRUCTION I l INo septic system permitted if public sewer is lik available within 200 feet.) Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line s I LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line I DISPOSAL PONDS ❑ k 'will be done in accordance with San Joaquin county ordinances, state laws, and 1 hereby certify that I have prepared this application and that the work rules and regulations of the San Joaquin Local Health Di%trict. 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 l 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 Califor ' The applicant st all r all r quire m c mpleta drawing on r arse side. t Signed X Title: I e moi?, rt,¢�. Date: F R DEPARTMENT USE ONLY r Application Accepted by Date �U Area � ! Pit or Grout Inspection by Date Final Inspection by Date Additional Comments- �LzD - ❑ 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 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO +-EH 13.24 1REV.1 r H 5] !3f- EH 14-25 —