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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 (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. Job Address -�. A City Lot Size egg- PM l /? Address ,, Phone Owner's Name ... w Contractor's Name S License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl `,y i DESTRUCTION ❑ i PUMP INSTALLATION EI SYSTEM REPAIR 1:14 OTHER 1-1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DIS O L FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS � V)❑ Industrial ❑ Open Bottom Q Manteca Dia. of Well Excavation Dia. of Well Casing I �'❑"Domesfic/PPivate❑" r v-I Specifications Pack ❑ Tracy Type of Casing 4 ❑ Public LJ Other. ❑ Delta Depth of Grout Seal Type of Grout I ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done 9 Well Destruction 21Z Well Diameter I Sealing Material (top 50'1 _ Depth I Filler Material-Welow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION Q (Noseptic yst m rmiitted if public sewer is avaInstallation will serve: Residenc 6 commercial— Other r �, —Number_of-living-units:-�—Number of bedrooms_ ° Water table depth � Character of soil to a depth of 3 feet: I SEPTIC TANK ❑ Type/MfgCapacity No:Compartments PKG. TREATMENT PLT. CJMethod of Disposal ' Distance to nearest: Well Foundation Property Line s j i • LEACHING LINE i"No. & Length of lines '2�� Total length/size r FILTER BED Q Distance to nearest: Well FFoundation�`17 Property Line SEEPAGE PITS Depth –Size ~' Number i SUMPS Q Distance'to nearest: Well _ Foundation ® � Property Line DISPOSAL PONDS ❑ t �� I hereby certify that I have prepared this application and that the work will be done in accordance with San Jo6quin_60i7nty 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 applica t call for all required inspections. Co plate drawing on rever Dater Signed XTom' FOR DEPARTMENT USE ONLY a Accepted by Date r Application r I( Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6761 Q Lodi 369-3621 ❑ IN nteca 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 CASH RECEIVED BY DATE PERMIT"N0. INFO �^ A !' + EH 13-244REV.101831(-� ND �Y� � EH 14-26 [[[ -