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APPLICATION FOR PERMIT " SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA 1 1 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 incompliance 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. t (� a! Job Address / i City Lot Size PM Owner's NameAddress Phone P r " � v�7r 1% s Contractor_�; Address rl License No/ 79 Phone (9 T` TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEME T ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK# SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Ll Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I`1 Public n Other Ll 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 U 5 Well Destruction ❑ Well Diameter Sealing Material (top1..50'-1`.1 Z Depth Filler Material (Bel ) TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION` l DESTRUCTION I I lNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial then r Number of living units: Number of bedrooms Character-of-soii•to-a'de0th of 3 feel: Water table depth SEPTIC TANK a-f.r ❑ Type/Mfg Capacity-0-100No. Compartments PKG. TREATMENT PLT. Cl I ti t I Method of Disp6,4al _ z , t Distance Yo nearest: Well L4'LV 5►- Foundation S_f [J Property.Line y , t LEACHING LINE Cly No.lel-ength of lines Total length/size { FILTER BED L1 Distance to nearest: WelllaO Foundation. Q___ Property Line _ f SEEPAGE PITS I ] Depth Size - Number MMp ❑ Distance to nearesv__-Well•0910A- -Foundation_(kr2 = Property Line r ISS POSAL 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 Dstrict. s 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 b ic6ine siibject 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, 1 shall employ persons subject to workman's compensa- tion laws of California." f The applicant r al qu" in pections. Comp]e drawing on reverse side. _� Signed X Title: Date: FOR DEPARTMENT USE ONLY i r Application Accepted by ktll, y Date 1 Area I Z?7 Pit or Grout Inspection by Date 5 Final Inspection by Date t Additional Comments: ❑ 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 f FEE AMOUNT DUE AM £ INFO OUNT REMITTED CK CASH RECEIVED BY DATE ��jj PERMIT'NO. tiEH 13-241REV.riN5) O g q - 1:1 r EH 1a-26 \}