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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT f _ O /b 16131 E. HAZELTON ON AVE., STOCKTON, CA Telephone (209)'466-6781 PERMIT EXPIRES TYEAR 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 wewpump and the Rules and Regulations of the San Joaquin Local Health District. /4 44City �JD Lot Sizecm ' s—'s�PM Job Address Address Phone Owner's Name Q�,� )7 Address License No. ��- � Phone &,7 Contractor ' TYPE OF WELLIPUMP: NEW WELL / WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION �" SYSTEM REPAIR ❑ yOTTH�E�R ❑ ��A y� DISPOSAL FLD.115_] POOP" LINE �,��-7,/�, E DISTANCE TO NEAREST: SEPTIC TANK h) � SEWER LINES � PITSISUMPS !lwl FOUNDATION AGRICULTURE WELL OTHER WELL i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS /_S ` E3 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Wel! Casing CSS k ❑ Industrial Type of Casing �Cy'PP I Specifications �mestic/Private ravel Pack ❑ Tracy YP � FI Public ❑ Other ❑ Delta Depth of Grout Seal c � Type of Grout +►✓�'`�� _ I Irrigation —.Approx. Depth i I Eastern Surface Seal Installed by Repair Work Done U�Type of Pump H.P. State Work Done Sealing Material (to 50'1 Well Destruction' ❑ .,t.Well Diameter 9 p - Depth Filler Material I8elow 501 r TYPE OF SEPTIC WORK: NEW INSTALLATION l'1 REPAIR/ADDITION I I DESTRUCTION I I Mo septic system permitted if public sewer is available within 200 feet.) r Installation will server Residence_ Commercial_ Other I Number of living units: Number of.bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity ' No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line r LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑: Distance to nearest: ' Well Foundation Property Line SEEPAGE PITS l I Depth Size Number SUMPS ❑ Distance to nearest: Well ..Foundation Property Line DISPOSAL PONDS ❑ - ----- # ` � I hereby certify that I have prepared this application and that the.work.will tie done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local health District. ,-, 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 th`e work for which.this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant a or all required inspec 'ons. Complete drawing on reverse side. f Title: Date: Signed X � . f FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date � Final Inspection by Date �� Additional Comments:W�'� ❑ 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 �],_CK FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO _ //�� nj(/J�/��) �(} f + EH 13-24(REV.I/n W /© J�� IJ -6 ✓" •�' �`'' / �� EH T4-28