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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) r 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 r �►� City d e Lot Size '3 t '"+ PMjl C_ ! Owner's Name Address E C a C Phone Contractor M Address,-39M License No.C,�r 7 j5`��1Phone L G TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLA EMENT ❑ DESTRUCTION ❑ j L PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ErSor/ DISTANCE TO NEAREST: SEPTIC TANK A.1A SEWER LINES lr DISPOSAL FLD. .V PROP. LINE 1 FOUNDATION f / 0 AGRICULTURE WELLOTHER WELL GLI /- PITSISUMPS AdA INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r Xlndustrial ❑ Open Bottom D Manteca Dia. of Well Excavation Dia. f Well Casing ❑ Domestic/ ❑ Gravel Pack ❑ Tracy Type of Casing� T Specilications F1 Public j COther F.1 Delta Depth of Grout Seal Type of Grout C ►z9 ` t'f!.-_- I i Irrigation AL5 Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump AV H.P. State Work Done — Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50'1 -- TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION l I i r U l No septic system permitted it public sewer is le 'in 200 feet.] Installation will serve: Residence_... Commercial^ Other Number of living units: Number of bedrooms Cf Character of soil to a depth of 3 feet: 7 ater table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 1 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 Diktrict. 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 parsons subject to workman's compensa- tion laws of California." The applicant must call for all required ins ctions. Complete drawing on reverse si e. , Signed X �1-�- r'+ Title: Data, O y i FOR D TME ONLY _ / Application Accepted by DateJ/ �� Area z f Pit o Grou Inspection byDate IA Q Final Inspection by Date '� o Additional Comments: , �rS a�- - ❑ 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 13-24Ii1EV."Abi EH 14.26 ~ -