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A APPLICATION FOR PERMIT SAN JOAQUIN:LOCAL HEALTH DISTRICTN0 Z 1601 E. HAZELTON AVE., STOCKTON, CA i Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDA (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" i Job Address 1 3 k City Lot Size -PM Owner's Name ddfess: i. Phone IM Contractor Address License No. Phone F TYPE OF WELL/PUMP: NE WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION _❑ PUMP INSTALLATION ❑ SYSTEM REPAIR El OTHER 11DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE k FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ! r" INTENDED USE TYPE OF WELL `PROBLEM AREA CONSTRUCTION.SPECIFICATIONS 4A-❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel..Pack ❑ ~Tracy Type of Casing Specifications r `Public r ❑ Other_ -' r ❑`Delta Depth of Grout Seal Type of Grout f+ ❑t Irrigation �Approx. Depth ❑Eastern Surface Seal.Installed by 1 Repair Work Done ❑{ Type of PumpJ�' H,P. _ State Work pone Well Destruction ❑' Well Diameter Sealing Material (top 501) Depth Filler Material l8elow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑i REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is r available within 200 feet.l I Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms i0 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 1 Distance to nearest: Well Foundation'`. Property Line LEACHING LINE ❑. No. &'Length of lines s Total length/size I" FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size — Number l SUMPS ❑ .Distance to nearest: Well Foundation Property Line 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 r u tions of the San Joaquin Local Health District. Home awn r or t!ons 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 an perso in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature C, th followi g: "I certify tha the perf rmance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws Califor ia." The appli t mus all for all n! in o L drawing%on everse side. ned X Title: Date: aR DEPART NT USE O1LpY 4 �] t Application Accepted by t l ��pate Area k Gr�l�.._. Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83x6385 Applicant- Return all copies for Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CKAI H RECEIVED BY DATE PERMIT'NO + EH 13-1401 EV.-1785] EH 14-28 L,•b�L u '�/