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F ' " APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 City, S0l�Lot Size PM 1 Phone Owner's Name Address z _1( Contractor Phone_ h Contractor 1d �/V �/ (_,&? Address License No. TYPE OF WELL/PUMP: NEW WELL 1-1WELLREPLACEMENT ❑ DESTRUCTION ❑ f PUMP INSTALLATION lQEp�STEM REPAIR ❑ - OTHER ❑ 4 DISTANCE TO NEAREST: SEPTIC TANK SEVI11�ER LINES DISPOSAL FLD. PROP. LINE FOUNDATION ,AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA, CONSTRUCTION SPECIFICATIONS k ❑ Industrial Ll Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ��- -9 Domestic/Private E3 Gravel Pack ❑ Tracy Type of Casing Specifications „ ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout LI-Irrigation" '—=�Ppiox—Depth"{'❑Eastem Surface Seal Installed 13y- Repair Work Done ❑ Type of-Pump- U ^.' H.P. State Work Dane ° Sealing Material Ito 50'1 �1 Well Destruction-- -❑ •-Well'Dia eter =-=— 9 P - Depth Filler Material (Below 50')--,-- TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is s available within 200 feet.) Installation will serve: Residence— Commercial_ Other i Number of Living units: Number of bedrooms i `� Character of soil to a depth of 3 feet: J Water table depth SEPTIC TANK ❑ Type/Mfg Capacity—PKG. TREATMENT PLT. ❑ rMethod of Disposal t I Distance to nearest: Well Foundation° �'" Property-Line f' LEACHING LINE ❑ No. & Length of lines r 4 F Total length/size w FILTER BED: ❑ Distance to nearest: Well �_- X; Foundation Property Line SEEPAGE PITS ❑ Depth Size Number i 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 -,: uin Local Health District rules and regulations of the San Joaq ._,,,. a-. ` 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:111 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion lawd,of California." The applcanntIl or al uired inspections. Complete drawing on revers ide. ; IL/4/ �r Signed X Title: Data: j FOR DEPARTMENT USE ONLY Application Accepted by Date l p" Area , GGss� Pit or Grout Inspection by Date Final Inspection by Date.�" Additional Comments: =' ❑ 5tk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 836-6385 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 GASH RECEIVED BY DATE PERMIT'NO. -+ EH 13-241REV.5/R5] EH 14.28