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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i ON AVE., STOCKTON, CA /�p ` I Telepho'he (209) 466-6781 f��` ' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I (Complete in Triplicate) Application is hereby made to the Sari 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 welt/pump and the Rules and Regulations of the San Joaquin Local Health District. 4 i City A V�_ Lot Size PM I Job Address i Owner's Name �� --`�� 11 Address r r3 �/ _License No. 2g! i Phone Contractor k1�!/ d6� � Address TYPE OF WELL/PUMP: NEW WELL El ; WELL REPLACEME T ❑ 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 1-1Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications vA FI Public ❑ Other f ❑ Delta Depth of Grout Seal Type of Grout _. J;, Fr igation ._.Approx. Depth i I Eastern Surface Seal Installed by - ! State Work Done_ t" Repair Work Done ❑ Type of Pump � r..I H.P. Well Destruction ❑ Well Diameter Sealing Material Itop 501 e` Depth Filler Material IBelow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I') REPAIR/ADDITION I I DESTRUCTION I i iNailabptic sy t m emitted if public sewer is avle 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 Distance to nearest: Well Foundation Property Line f LEACHING LINE ❑ No. &'Length of lines Total length/size l FILTER BED 11 Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depths Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line f DISPOSAL PONDS ❑ ork will be done in accordance with San Joaquin county ordinances, state laws, and I hereby certify that I have prepared this application and that the w 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,I shall employ persons subject to workman's campensa r tion laws of California." The applicant must ail f r required inspe ons. Complete drawing on reverse side. I k Signed Title:. l �oL' �� Date: - ", F R DEP TMENT USE ONLY Application Accepted by Date ` •fJ`�� Area Pit or Grout Inspection by L Date Final Inspection by �. Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 i Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE PERMIT NO. INFO +,EH 13.21 PREY.�/n sl 2� 1 LA Er+14-2$ ..7