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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE.;.STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES'1 YEAR FROM DATE ISSUED (Complete in Triplicate) ;' r ' 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 w 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. ` - 1 ,j Job Address I _ e- City /O l of Size_��x a PM -Owner's Name `" Address , Phone a - �� .< Cbntractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 PUMP.INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ �J DISTANCE TO NEAREST: SEPTFIC'TANK SEWER LINES DISPOSAL FLD. PROP. LINE Q FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE - 'TYPE OF WELL PROBLEMAREA CONSTRUCTION SPECIFICATIONS r. ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack,. ❑ Tracy Type of Casing ! Specifications ❑ Public ❑ Other 0. ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal,Installed by Repair Work Done ❑ Type of Pump ' H.P. State.Work Done_ Well Destruction ❑ Well Diameter t Sealing Material (top 50') Depth Filler Material (Below.50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ -DESTRUCTIONINo septic system permitted if public sewer is vailable within 200 feet.) Installation will serve: Residence Commercial Other Number of living units: Number of bedrooms ' Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg I ' Capacity No. Compartments PKC. TREATMENT PLT. ❑' x Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑~ No. & Leng b of.lines 1. Total length/size FILTER BED ❑:. Distance to nearest: Well ' _'Fouridatiori •Property Line SEEPAGE PITS ❑ Depth 11=' Size # ' Number SUMPS ❑„ Distance to nearest: Well Foundation Property Line _ DISPOSAL PONDS ❑ 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. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for-which-thie`` rmit 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 the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." i The applicant st call for all required inspections. Complete drawing on reverse side. Signed X 9 Title: e4-zDate: �Z`1 7'p FOR DEPARTMENT USE ONLY Application Accepted by « Date Area QV Pit or Grout Inspection by Date Final Inspection by "t Date_„ is Additional Comments: -� s ❑ 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 FEE i INFO AMOUNT DUE; i AMOUNT REMITTED CK RECEIVED BY DATE PERMI-r NO. + EH 13-241REV.5ix5Y S SUV E -q. LX �'4-01 �j�.�I��2�EH 14.28 11 p _