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1 APPLICATION FOR PERMIT rl l LlSAN JOAQUIN LOCAL HEALTH DISTRICT /� Y' 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 4 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. 22 c Job Address �-3 -2 ZJ r� //� City c'ifu- \Lbt Size � Lf n PM Owner's Name �eG Phone Address �� -- Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION El PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ � DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES —� i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �7 Dia. of Well Casing Industrial ❑ Open Bottom C1Manteca Dia. of Well Excavation Specifications r] Domestic/Private E) Gravel Pack ❑ Tracy Type of Casing f•1 Public ❑ Other n Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by r Repair Work Done ❑ Type of-Pump H.P. State Work Done Well Destruction EIWell Diameter Sealing Material (top 501 Depth Filler Material (Below 50') F SEPTIC WORK: NEW INSTALLATION I I REPAIR/ DITION l I DES RUCTION I I (No septic system permitted if public seweri is av ila a within 200 feet.) Installation will serve: Residence_ Commercial_ Other i Number of giving units: ` –`Number of beth6bms• Character of soil to a depth of 3 feet: Water tab{e depth SEPTIC TANK ❑ Type/Mfg Capacity /144-1 No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: well zefl Foundation Property Line ` LEACHING LINE f No. & Length of lines _ �t�, .Prt /size FILTER BED O Distance to nearest: Well oundati6nperty Line, $EEP�AGE PITS 11 Depth Size_— Number i [-1 Distance to nearest: Well _ Foundation Property Line DI ❑ 1 hereby certify that I have prepared this application and that the work will be doee`in accordance with San Joaquin county ordinances, state laws, and rules and regulations of-the San Joaquin Local Health DItrict. Home owner or licensed agent's signature certifies the following: "I certify that in4he performance of the work for wfli6ih this permit is issued, I shall not employ any person in such manner as to become subject to workman's oompensaiion law(of California,"-Contractor's hiring or sub-contracting signature certifies the following: "I certify th�t 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." The applic t u call for all r quired in ctio . Complete drawing on reverse side. ' Bate; +J ` Signed X L1.-�i3�/ ✓1/ Title: FO MENT-UWQNLY Application Accepted by Date r Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ 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 CASH RECEIVED BY DATE PERMIT NO. INFO a.EH13-211REV.tiH51 EH 14-26