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li 4 a� APPLICATION FOR PERMIT 7_ FAQ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA IT7M,47 1-7-- Aes Telephone 12091 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. Job Address _�� _ N1 �- —� City� Niot Size PM ��j�111r 4 Owner's Name 1 u — Address 'r�• � 3 Phone fir' s Contractor 1 Address License No., Phone TYPE OF WELLIPUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ ' PUMP INSTALLATION;F0 SYSTEM REPAIR ❑ OTHER'0 o„1 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 �omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications�.,,,,� ❑ Public ❑ OtVer ❑ Delta Depth of Grout Seal — Type of Grout?r /UCf I I Irrigation 7-M.Approx. Depth I I Eastern Sur a Seal Installed by ld✓�DD�� N� - Repair Work Done ❑ Type of Pump H.P. ate W rk Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 U I` Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted if public sewer is available within 200.feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms q 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 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED D Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number E SUMPS L� 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 I 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 7 ` 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-T[ I tion laws of California." F The applicant requir tions. Complete drawing on 0 Ode. 1 Signed X 'e Title: Date: U 43 FOR DEPARTMENT USE ONLY Application Accepted by Date 5 I Area r Pit or Grout Inspection by - , Date r Final Inspection b_y- J Date Additional Comments: ❑ 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 2oD9, Stk., CA 95201 x II N € FEE AMOUNT DUE AMOUNT RE ITTED CK RECEIVED BY DATE PERMIT'NO INFO CASH ♦ EH13-241 REV.EiK51 - EH 14-26