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- APPLICATION FOR PERMIT a < s SAN JOAQUIN LOCAL HEALTH DISTRICT '' 1601 E. HAZETON 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 W City f6 Lot Size �1+ PM Owner's Name ` � Address Cra Phone Contractor .v Address License No Phone TYPE OF WELL/PUMP: NEW WELL El REPLACEMENT ❑ DESTRUCTION ❑- PUMP INSTALLATION ❑ I SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. 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 Q Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public Ll Other F] Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth l I Eastern I -Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material [top 50') Depth Filler Material l8elow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION [ I REPAIR/ADDITION D4 DESTRUCTIONX INo septic system permitted if public sewer is available within 200 feet.] Installation will serve: Residence_ Commercial_ Other f Number of living units: _e-1 Number of bedrooms_� Character of soil to a depth of 3 feet: 41:10404! Water table depth �� t SEPTIC TANK P5, Type/Mfg 'Va VO'_O_,1&�3_ Capacity No. Compartments PKG. TREATMENT PLT. ❑ 1,, 1-11 Method of Dispoyl Distance to nearest: Well n2 Foundation � Property Line LEACHING LINE 00- No. & Length of lines 1400 Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line i Ie) I SEEPAGE PITS Pl� Depth f07_S Size Number SUMPS Ll Distance to nearest: Well 6C'J f Foundation /!1 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 counly..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 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: "I certify that in the performance of the work for which this permit is issued, l shall employ persons subject to workman's compensa- tion laws of California." ' The applicant m II for a required inspections. Complete-drawing on reverse side. 1 Signed X Title: �• / "`'�L- Date: FOR DEPARTMENT USE ONLY 92 1L� Application Accepted by -r-21 � Date Area Pi r Grout Inspection by Date LZ-1_23Final Inspection by Date —Addifional Comments: - Ll Stk 466-6781 ❑ Lodi 369-3621 ❑ Ma era 623-7104 ❑ Tracy 835-6385 Appilcant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOU T REMITTED CASH CK 0 RECEIVED BY O TE PER..MMIT7NO. + ER 13-24(REV.1/95) T—M EH 14-26 / %6