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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON 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, r` f Job Address City Lot Size PM fC�ti l �A� U 64L.5 Address Phone Owner's Name — �-�� Contractor rC(Cf ef. Address b X License No.Z ' .Phone r TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT-C7 DESTRUCTION ❑ PUMP INSTALLATION ❑w SYSTEM REPAIR O OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES DISPOSAL FLD. PROP. LINE " . + PITS/SUMPS FOUNDATION AGRICULTURE WELL OTHER WELL i INTENDED USE TYPE OF WELL- r PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom r ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack, ❑ Tracy Type of Casing Specifications (� f1 Public 1=l Other ❑ Delta Depth of Grout Seal Type of Grout__. y I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done LJ Type of Pump H.P. YSte-WorkDone Well Destruction ❑ Well Diamet&r a.. Sealing Material ftop 501 EJ' Depth Filler Material (Belo 50') — Ire TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION DESTRUCTION I I INo septic system permitted if public sewer is 0 t available within 200 feet.) f^ Installation will serve: Residencev f Commercial_ Other V !` Number of living units: Number of bedrooms 3 ✓r� y`V Character of soil to;depth-of 3 feet: S-/Xd. Water table depth SEPTIC TANK z Type/Mfg. Capacity— No. Compartments i ` - Method of Disposal PKG, TREATMENT PLT. ❑ # ;„�y.--�.-..r.; t Distance to nearest: --Well -~- ¢� -foundation Property Line LEACHING-LINE No. & Length of liries� �r1otat length/size FILTER BED ❑ Distance l to,nearest: Wel -..._..'°'" Foundation Property Line , F SEEPAGE PITS i I Depth t _ Size Number SUMPS C1 Distance to nearest: Wetll- ` 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 rules and regulations of the San Joaquin Local Health Diltrict. ` ` +;_1_�_ 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 Riririg or sub-contracting signature s 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 compensa- tion laws of California." The applicantmust ca for all re uire inspections. Complete drawing on reverse side. 1t3LW_ Signed X Title: F � Date: i FOR DEPARTMENT USE ONLY��e Application Accepted by Date Area tri " Pit or Grout Inspection by , Date Final Inspection by - Date 3�� f ' Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823.7104 C1 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 i INFO AMOUNT DUE + AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT•NO. } +.EH13-241REV.11s851 0 -007 EH 14-26 .. I