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APPU ION FOR PERMIT SAN JOAQUiN L'0VCAL 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 i 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 G City - Lot Size. PM Owner's Namerd�� e Address S ✓�� Phone Contractor Address Y 41 License No. I1 Phone a— TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ t DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL 1 • PITS/SUMPS INTENDED,USE —TYPE_OF WELL, .PROBLEM,ARE4;:CONSTRUCTION-SPECIFICATIONS v❑ Industrial Cl Open Bottom ❑ Manteca Dia. of Weil Excavation Y �_ Dia. of Well Casing "Domestic/Private 171 Gravel Pack 11 Tracy Type7of Casing Specifications ❑ Public ❑ Other ❑ Delta De '~' r` ' ^" n ^' pth of Grout Seal Type of Grout �J ❑ Irrigation --Approx. Depth Eastern 'S a Seal Installed by Repair Work Done J Type of Pump H.P. ! State Work Done w Well Destruction ❑ Well Diameter Sealing Material (top 50') i Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is "i available within 200 feet.), f + Installation will serve: Residence_T—Commercial,,— Other Number of living units: ( Number of bedrooms Character of-soil to a depth of 3 feet: j w or SEPTIC TANK L1 Type/Mf table depth g Capaci No. Compartments n PKG. TREATMENT PLT. ❑ Method of Disposal s Distancerto nearest:' Well Foundation Property Line { I Fie! I LEACHING LiNE ❑ 'No. & Len ines _ ; _ Total length/size --- f FILTER BED ❑ Dis a to nearest: . Well Foundation Property Line T , l SEEPAGE PITS ❑ �_'Depth___i:•----.-.--,..Size Number i 1 .1 SUMPS ❑ Distance to nearest: Well Foundation- Property Line " xr Q.181110SAL PONDS ❑ ' hereby certify that I have preparedthis application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and r rules and regulations of'the,zSan Joaqui<Local Health District. , Home owner or licensed agent's signature certifies the followin9: "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 tfie work for which this permit its issued, i shall employ persons subject to workman's compensa- tion laws of California." r The a, r -•'`` t . st call for a quire spec s. Complete drawing o -reverse side. = r Signed X Title:' ' i Date: ff FOR DEPARTMENT USE ONLY h Application Accepted by Date S / a Area .< Pit or Grout Inspecti n bate " _Einal_lnspection by Date w j Additional Comments: ; ❑ Stk 466-6781 . ❑ Lodi .369-3621 ❑.Manteca 823-7104 ❑ Tracy 835-6385 i 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 CK RECEIVED BY INFO CASH DATE PERMIT'NO. + ENI 3-24 tREv.I iH 51 �' U ( 'j/�n /► - ., EH 7428