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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT II 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED A (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 e Sn Joaquui aAm Local Health District. 3/ .75^ '{ f��// S Job Address 7 City Lot Size PM ♦ } I' ssF i.M Phone ) Owner's Name -.w. �. ,4. � : — ddress License IVa: �Phone Contractor TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ ' SYSTEM REPAIR ❑ i OTHER 71 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP: LINE FOUNDATION +. AGRICULTURE WELL" OTHER WELL E F'ITSI5UMP5 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS. ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia„of Wall Casing ❑ Domestic/Private D Gravel Pack ❑ Tracy Type of Casing Socifications iType of Grout ”" (-1 Public F Other s Cl Delta Depth of Grout•Seal —" I I 1 Irrigation —,Approx. Depth N_I I Eastern Surface Seal Installed bye t'} s5" Repair Work Done LI Type of Pump•w---�" �"�=f H.P. I State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 501 F it Depth Filler Materia el `) TYPE OF SEPTIC WORK: NEW INSTAL TION f I REP AIR/ADDITI N STRUCTION I 1 INo'septic.system permitted if public sewer is 'r'"""""""C"�available.within 200 feet.) Initallation will serve: Residence_ Commercial— Other i Number of living units: Number of bedrooms�k Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ ,Type/Mfg Capacity i No. Compartments d PKG. TREATMENT PLT- [DMethod of Disposal _ -. j distance to nearest: WeII Foundation Prop•_perty.Li�e Of < LEACHING LINE ❑ .: No. & Length of lines Tot I I ngthlsize FILTER BED ❑ :I"Distance to nearest: Well oundation Property Line ! SEEPAGE PITS f II Depth2, Size 2L,�y _ Nu b r SUMPS ❑'�, Distance to near t: Well /f1 V Fountkation b� �Property Line DISPOSAL PONDS ❑:I { 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 ruies 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 j 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 compensa- tion laws of California." II -t r? The'applicanXnust call for ' equired ictions. Complete drawing on reverse side. � i SignedTitle: Date: / .T Ak, - - � FOR DEPARTMENT USE ONLY i Application Accepted by Date Area — ' Pit or Grout Inspection by Date Final inspection by Date Additional Comments: I ❑ 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 ! ' FEE pMQUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"NO. F INFO CASH � - /�_ , +.EH 13-24(REV. /a 57 2/ _,� �