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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 Y, I�r PERMIT EXPIRES 1 YEAR FROM DATE ISSUED / v' f( J (Complete in Triplicate) va/-r 17' '7 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 welllpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address � �/�� City of Size PM f a Owner's Name r Address Phone Contractor r Address icense No.�_Phone �g499 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLAC MENT ❑ `h DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE.TO NEAREST:,SEPTIC,TANK, .SEWER.LINES._ DISPOSAL FLD_._ PROP. LINE FOUNDATION ___t4_,___-AGRICULTURE WELC;L OTHER WELL 1 PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS e I ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing I ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public r- Other r ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation —.Approx. Depth i l Eastern Surface Seal Installed by ' Repair Work Done 0 Type of Pump H.P. State Work Done I Well Destruction ❑ Well Diameter ' Sealing Material (tap 50') 1 j Depth i s Filler Material (Below 501 t TYPE OF SEPTIC WORK: NEW INSTALLATION I'I REPAIR/ADDITION 11—DESTRUCTIONN INo septic system permitted if public sewer is available within 200 feet.) Installation'urill serve: Residence Commercial____ Other Number of living units: Number of bedrooms Character of soil to a depth of feet: 1 Water table depth SEPTIC TANK ❑ Type/Mfg. Capacity Nol Compartments PKG. TREATMENT PLT. ❑ .. ._W n. Method of Disposal Distance to nearest: Well Foundation Property Lrine LEACHING LINE' -z D No. & Length of lines � ,Total length/size i FILTER BED r. ❑ Distance to nearest: Well Foundation f Property Line TSEEPAGE PITS 1 i Depth I Size Number SUMPS ❑ Distance to nearest: Well Foundation - Property tine I 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 District. �l i Home owner or licensed agent's signature certifies the following: VI certify that in the performance of the work for which this permit is issued, I shall not t employ any person in such manner as to become subject to work man'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." The applicant st call for II ;eq�jd,.m ,cti n. Completd drawing on reverse side. 1 aw Signed X Title: Date: } FOR DEPARTMENT USE ONLY Application Accepted by Date ZU Qrea Pit or Grout Ins pecti y Date Final Inspection by A Date T� ✓'� ' Additional Comments: ___ _ t L' [21 SE //f e -5 ivc-D� ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 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 CK 0 RECEIVED BY DATE PERMIT NO. INFO ♦.EH 13-241REV.IiH s) � ✓ f � EH 14-26 VVV