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APPLICATION FOR PERMIT s SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone {209) 466-6781 r 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 oSan Joaquin Local Health District.10 Gf Job Address / 4 City Lot Size PM G ' / Owner's Name . Address t0 Phone Contractdj ddress �•� License No. �7Z6 Phone TYPE OF WELLY UMP: NEW WELL ❑ 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 Well Excavation Dia. of Well Casing ._ .. -. -_._ - '' —r f i.;- ❑ pomestic/Private C] Gravel Pack racy ' `""Type of Casing Specifications M Public C] Other n Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx.'Dep th i I Eastern Surface Seal installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 i Depth Filler Material (Below 501 U TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I ) DESTRUCTION i 1 INo septic system permitted if public sewer is 9 f available within 200 feet.I \1\ Installation will serve: Residence I Commercial— Other Q Number of living units: Number of oms `F1 Character of soil to a depth of 3 feeC' Water table depth 06 f SEPTIC TANK )F( TypelMfg t'C ► � Capacity�cWQ ~- No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation_-"�4 Property line __. LEACHING LINE No. & Length of lines "- Total length/size )(CR .I i FILTER BED ❑ Distance to nearest: Well Foundation Foundation � Property Line i SEEPAGE PITS 1 Depth Sizeel Irumber i SUMPS Ll Distance to nearest: Well Foundation /D Property Lines j DISPOSAL PONDS ❑ hereby certify that I have prepared this application-and-that-the-wotk-will be done in accordance with-San"Joaquin county ordinances, state laws, and rules and regulati6ns of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify_thatin'the performance of the work for which this permit is issued, I shall not employ any person.in such manner as to become subject io- 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'fbr which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." 4 The applicant mu call for quXinsporfi�ns plete drawing on rave a de. " I _ Signed Title: 1 ' Date: . V 'FOR)?EPARTMENT lJSE.ONLY r p Application Accepted by ___._ Date Area Pit Grout Inspection byflora �, y Final inspection by�� - �� Dat/f `LLQ Additional Comments: 0 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 � r FEEAMOUNT DUE i AMOUNT REMITTED GK RECEIVED BY DATE PERMIT NO. INFO GASH ` -r.EH 1324 iREV.tiNs1 ��, `y iE�H�14.28 � 4"