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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E: HAZE T ON AVE., STOCKTON, CA y Telephone (209) 466-6781 �$ �5 � � f PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) .5j4A P' � �` ✓u 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. e s Job Address // City � _�j /t. Lot Size PM Owner's Name P hone Contractor Address icense No. Phone TYPE OF WELL/PUMP: NEW WELLA, WELL REPLACEMENT ❑ DESTRUCTION ❑ I t PUMP INSTALLATIONNI SYSTEM REPAIR ❑ OTH R 1-1r l,. DISTANCE TO NEAREST: SEPTIC TANK J(� 'r SEWER LINES _._� DISPOSAL FLD._�'�ROP. LINE Z 7 ! FOUNDATION ' _ AGRICULTURE WELL IYOTHER WELL / pITS/SUMPS " INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation/Z, i Dia. of Well Casing /10 Domestic/Private Gravel Pack ❑ Tracy Type of Casing f� ' Specificationsr ❑ Public ❑ Other r ❑ Delta Depth of Grout Seal Type of Grout � r ❑ Irrigation � Approx. Depth ❑ Eastern Su ace Seal Installed by v\ #4 Repair Work Done ❑ Type of Pump �� H.p. State Work done_ M Wel! Destruction ❑ Well Diameter 1 ,Sealing Material Iiop 50'I �` k Depth I ! Filler Material (Below 501 Z. \� TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial Other Number of,.living units: Number of bedroomsf 5 Character of soil to a depth of 3 feet: F r Water table depth, SEPTIC TANK •. r - ❑ Type/Mfg s ENo. Compartment e PKG. TREATMENT PLT. ❑ rt { __. Method of Disposal Distance to nearer Well} Foundation Property Line i t \D .s LEACHING LINE ❑?�No. & Length of lines Total length/size s 1 `O FILTER BED El Distance to nearest: i Well Foundation property Line SEEPAGE PITS ❑ Depth Size. �_ __.3__ Number i y SUMPS ❑ .Distance to nearest: Well Foundation Property Line t I DISPOSAL PONDS ❑ ---�— �- --j �' l I hereby certify that t 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 th i work for which this permit is issued, I shall not i 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 perit is issued;.)shall employ persons subject to workman's compensa- tion laws of California." p y The applicant m c I r require c'ons. Complete drawing on re side. I Signed X '1 Title: C L2 L�/_ �I Date: FO DEPARTMENT USE ONLY l Application Accepted by Date '� l Area _ r Pit or Grout Inspection by— .D^at�er�- Fina! Inspection by Date Additional Comments: ❑ Stk 466-$781 ❑ Lodi 369-3621 i 0-Manteca 823-7104 El-Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Servicer 1601,E. Hazelton AVe:r•P.O. Box 2008, Stk., CA 95201 FEE MOUNT DUE AMOUNT REMITTED CK RECEIVED-BY DATE PERMIT NO. INFO ASH + EH 13.241REv. EH 14.28