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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT fh 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 wit an Joaquin C unty dinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. r r ter^ Job Address �� City Lot Size PM Owner's Nam& Address Lfl. Phone Contrac r ctj. Address .©` �O� ��a ,License NO.J V2z. Phone 3& /O TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ .. PUMP INSTALLATION L] _+_. SYSTEM REPAIR Ll OTHER ❑ DISTANCE TO NEAREST:_SEPTIC TANK Y SEWER LINES DISPOSAL FLD. PROP. LINE FOUNbATION 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ 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 _ W Well Destruction ❑ Well Diameter Sealing Material (top 501 .-- Depth Iter Material (Below 50 -� 4 x TYPE OF SEPTIC Depth NEW INSTALLATION ❑ EPAI ADDITIONU5ESTRUCTION-E3-(No septic system permitted if public sewer is yy ., a n ! available within 200 feet-.)l Installation will serve: Residence— Commercial L -Oche -Number of living units: 10 Number ofkbedrooms --- Character.of soil to a depth of 3 feet: Water table depth x •SEPTIC TANK R ❑ `Type/Mfg"- 49 ` . Capacity _ No. Compartments 9 PKG. TREATMENT PLT. ❑ 1. J. Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. &'Length of lines Total length/size f FILTER BED p Distance to nearest: Well Foundation Property Line SEEPAGE PITS 117 _Depth Size Number SUMPS.- r l ❑ `Distance to nearest: Well� _ Foundation Property Line=.y� DISPOSAL PONDS -0. . _ I hereby certify that Ihavo,prepared this application and that the work will be hone in-accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Wealth District. Z Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permitis 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 shalhemploy persons subject'tn wo rnan'9-c-ompbnsa: tion laws of California." The applicant ust call for a eq 'ed inspections. Complete drawing on reverse side. Signed Title: Date: FOR DE RTMENT USE ONLY Application Accepted by� Date Area �r Grout Inspection by to nal Inspection by ate 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 955201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK 11 CASH RECEIVED BY DATE PERMIT NO. + EH13-24 IREV-t/8 51 EH 10.26 t