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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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 Job Address 10 City Lot Size u C Ir-C PM Owner's Name Address a • 5y Phone ContractorAddress �- License Nor 3 = � Phone, a TYPE OF WELL/PUMP; NEW WELL WELL REPLACEMENT ❑-- DESTRUCTION ❑ PUMP INSTALLATION�. SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 1SEWER LINES DISPOSAL FLD. PROP, LINE, FOUNDATION AGRICULTURE WELL OTHER WELL /1 E1 A1? PITS/SUMPS Aro INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t• ❑ Industrial Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing );Domestic/Private x ❑ Gravel Pack ❑ Tracy Type of Casing �rG- Z Specifications j , 11 Public -_ACIOther Fl Delta Depth of Grout Seal �� Type f Grout I I Irrigation Z pprox. Depth I Eastern Surface Seal Installed bVk1d � V e 2r ri a _ Repair Work Done L7 Type of Pump H.P.w� State Work Done Well Destruction ❑ Well Diameter . , Sealing Material (top 501 (q Depth Filler MateriallBelow 50'1 -- _ TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION i I DESTRUCTION I 1 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 4 Distance to nearest: Well Foundation Property line r I LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to'nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size _ Number SUMPS L1 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 .rules and regulations of the San Joaquin Local Health Di'%trict. 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, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicant mus call for all required inspections. ComAete drawing on reverse side. ~ IS-/ A Signed X / Y d l n�l „��! Title: Date: FOR DEPARTMENT USE ONLY �^ Application Accepted by Date;>�Z Area� . Pit or rou Inspection by yrDateL Final Inspection by Date / Additional Comments: 14 A'ot- El Stk 466-6781 ❑ Lodi 369- 1 ❑ Manteca 823-7104 racy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE \ INFO AMOUNT DUE AMOUNT REMITTED CASH .CK 4 RECEIVED 13Y DATE PERMIT-NO. i.EH13-241REV.1/Hsl EH 14-26 Z�Z