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APPLICATION FOR PERMIT .P a SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON 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 " City Lot Size PM Owner's Name `- `Address ' '~ Phone - �Contra ctor�� r 'Y ddr ss�`/ ' License No. " —Phone717— ` TYPE OF WELL/PUMP: R NEW ELL ❑ WELL REPLACEMENT Q DESTRUCTION ❑ i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST.iSEPTIC 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 ElGravel Pack 44'10 Tracy Type of,C sing Specifications r ❑ Public ❑ Other aC .pelta Depth•of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern 'esurface Seal Installed by Repair Work Done ❑ Type of Pump H.PI g State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501)• - S Depth Filler Material.lBil-SlIlou TYPE OF SEPTIC WORK:—NEW-INSTALLATION K REPAIR/ADDITIO DESTRUCTIO No'septic system permitted if public sewer is f ' *available within 200 feet.) I• Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms :+v XF f I Character of soil to,,a depth of 3 feet: -Water table depth SEPTIC TANK ❑ Type/.Mfg l Capacity tJf� No. Compartments PKG. TREATMENT PLT-E j J �,��'� ,,,�� }}} Method:of Dispo I f Distance to nearest: Well Foundation Property tine LEACHING LINE LlNo. & Length of lines Total length/size 0 FILTER BED ❑ Distance to nearest: Well ZL2 o Foundation J Property Line t' t t SEEPAGE PITS ❑ Depth Size Number i 1 SUMPS ❑ Distance to nearest: Well 1)100 Foundation n ¢ Property Line e DISPOSAL PONDS ❑ r 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. a 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 nat i employ any person in such manner as to become subject to workman's compensation laws of Gal'rfornia."Contr9t is hiring or sub-contracting signatufre 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- J tion laws of California." The applicant must call for lirequired i spections. Complete drawing on reverse side, t.v A A Signed Title: Date: f W r-; FOR DEPARTMENT USE ONLY / ! rZ Application Accepted by Date JA_re'aI �P�t or Grout Inspection by Y Date Final Inspection by "� Data L�2 vAdditional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Healtf Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t I FEE If INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE(, PERMIT"NO. - ,..#r+ EH 13-24(REV.5 851 A/ EH 14-28 f i �,