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APPLICATION FOR PERMIT ~ SAN JOAQUIN LOCAL HEALTH DISTRICT pit b!rG ala 7 1601 E. HAZE T ON 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 9 City Lot Size PM Owner's Name ])/e/re u E z Address Phone ~�� Contractor Address �/ a License No.06gSr 2,7&_Phone TYPE OF WELL/PUMP: NEW WELL Cl WELL REPLACEMENT ❑ DESTRUCTION ❑ E PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE r TVP OF VtilELL PROBLEM AREA- CONSTRUCTION SPECIFICATIONS ,T- - -- - ❑ Industrial El Open Bottom LJ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domesticl Private ❑ Gravel Pack , ❑ Tracy Type of Casing Specifications F] Public f 7 Other F1 Delta Depth of Grout Seal Type of Grout I I Irrigation �..Approx. Depth ' I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done # Well Destruction ❑ Well Diameter Sealing Material (top 501 [ Depth Filler Material (Bela ') d TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION yr DESTRUCTIO . (No septic system permitted if public sewer is t available within 200 feet.) f Installation will serve: Residence -Commercial__ Other ` Number of living units: --�— Number of-be rooms 2- Character of soil to a depth of-.3 feet: e-1 Water table depth ' - a i Capacity No. Compartments SEPTIC TANK ❑ Type/Mfg t PKG. TREATMENT PLT. ❑ -Method of,Disposal } Distance to nearest: Well Foundation Property.Line ti rX LEACHING LINE Lf No. & Length of lines —Z Total length/size r o FILTER BED El Distance to dearest.� Well Foundation^2.4 Property Line i i SEEPAGE PITS r I ;Depth _f _Size Number SUMPS Qr] Distance to nearest: Well Foundation ?1> `_ Property Line 2.0 r DISPOSAL PONDS ❑ 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 Di1trict. 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." � 4 " The applicant must call for all required'inspec'tons. Complete drawing-on reverse side: - , Signed X Title: Date: i FOR DEPARTMENT USE ONLY Date I`� -..- Area Q Application Accepted by Pit or Grout Inspection byDate Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 .❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA zic, FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE INFO +.EH 13-24(REV.1(x5) , 1/1 EH 14-26