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4. 4 { 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 x } (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herei described Th1s 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. ' '"" � I Jab Addre City Lot Size PM Owner's Namfg Address IY / Phone f(' ContractorS�o'�a—� S7C8� Address License No-:;2201/a Phone TYPE OF ELL/PUMP., NEW WELL ❑ WELL REPLACEMEN ❑ 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public C1 Other ❑ Delta Depth of Grout Seal " � ElIrri Irrigation Type of Grout g --Approx. ❑ Eastern Surface Seal Installed by i Repair Work Done Ll Type of Pump H.P. State Work Done T Well Destruction ❑ Well Diameter " Sealing Material (top 50') Depth j Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITIUNN DESTRUCTION ❑ (No septic system permitted if public sewer is I available within 200 feet.) Installation will serve: Residence Commercial Other units: Numbe Number of living �rof bedrooms F� �_ i Character of soil to a.depth of 3 feet:,=? � Water table depth ' SEPTIC TANK ❑ Type/Mfg - Ca acit P Y No- Compartments PKG: TREATMENT PLT- ❑ C_--ef i. Method of Disposal Distance to nearest: Well Foundation Property Line i LEACHING LINE ❑' No. & Length of lines Total length/size FILTER BED 1 �' �,� '� Distance to nearest: Well Foundation �C - °Property Line SEEPAGE PITS Depth Size Number SUMPS, - .- Distance to nearest:- Wells Foundation [oX"T DISPOSAL PONDS �� I aQ� Property Line X 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 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 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 applicant must call for all required inspections. Complete drawing on reverse side. } Signed X i Title: Date: FOR DEPARTMENT USE ONLY - Application Accepted by ll Date l 1 Area Pit or Grout Inspection by Date Final Inspection by �. Date` Additional Comments: + ❑ Stk 466-6781 'El 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 AMOUNT DUE AMOUNT REMITTEDCK f INFO. ASH RECEIVED BY DATE PERMIT-NO. + EH 13-24(REV.t/H 5) O .. ✓' ' - . EH 14-28CA-1 � ... .. . �y...z,.. .