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t APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 is 1 L�k�l'C7 Rot Size PM ` �A- City Owner's Name L4 r t�S Phone /�j� y�I`13 Contractor. Address = License No. Phone TYPE OF WELL/PUMP: NEW WELL C7 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ 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 Wel! Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1"1 Public Ll Other Cl Delta Depth of Grout Seal Type of Grout r I I Irrigation —.Approx. Depth I 1 Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ _ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION l 1 DESTRUCTION INo septic system permitted if public sewer is available 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 Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal o Distance to nearest: Well Foundation _ Property Line ? V' LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line t SEEPAGE PITS 11 Depth Size — Number �y 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 n rules and regulations of the San Joaquin Local Health District. U 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, I shall employ persons subject to workman's Mrnpensa- tion laws of California." The applicant must call for art required inspections. Complete drawing on reverse side. Signe X Title: Date: � �. FOR DEPARTMENT USE ONLY Application Accepted by � �►^'� Date Z` p Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: e �►'�t ► 1 ci Q4�3`p ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca -7104 ❑ Tracy 835-d85 Applicant - Return all copies to. Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9520 L FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED By DATE PERMIT'NO. INFO ('�(� + EH 13-241REV.I In 57 � S� AA_ 0D EH 14-2a