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P APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �I 1601 E. HAZE;TON AVE., STOCKTON, CA Telephone (209) 466-6781 h PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ,i (Complete in Triplic6#e) 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 7 City Lot Size pM --Owner's Name " Address - Contractor ?�. < _ Addresscense No.� ' TYPE OF WELL/PUMP: ,� NEW WELL ❑ y Y,; t Phone . WELL REPLACEMENT ❑ } DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ .1 DISTANCE TO NEAREST: SEPTICTANK "" ' OTHER ❑ SEWER LINES '" DISPOSAt`FLD• PROP. LiNE' FOUNDATION. AGRICULTURE WELL -OTHER WELL 1 PITS/SUMPS INTENDED USE TYpE OF WELL' PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial -A, ❑ Open Bott6m .� f ❑ Manteca Dia. of Wel! Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ,. �❑ Tracy it YType of Casing `` r l. s❑Public ❑ Other ❑ pelma Specifications Depth of-Grout Seal Type of Grout Q Irrigation *�`- `_ -Approx..Depth = ❑ Eastem,: ." .Surface Seal Installed by u Repair Work._Done :❑ Type of Pump �- H.P. I f,,. ,,,r State,Work Done ^+ - Well Destruction ❑ Wel! Diametei Seating Material (top 56) Depth Filler Mate.rial_(:Below_50'I '�'•�` - - .�. 1} - TYPE OF SEPTIC WORK: NEW INSTALLATION: REPAIRlPEDITION ❑ DESTRiJCT_ION ❑I(N eptic system permitted if public sewer is �� t availl be within 2 feet.) Installation will serve: Residence Commercial Other y� j D i Number of livingunits: �'I Number of bedr oms Character of soil to a depth of 3 feet: ri� of SEPTIC TANK l E Water table depth Type/Mfg gf-106— Com , Capacity--taloa- PKG. ' TREATMENT PLT. ❑ j'No. Compartments e f Method of Disposal \ t Distance to nearest: Well �P ld. I` Foundation Property Line LEACHING LINE 9--No.T& Length of fines j FILTER BED ❑ Distance to nearest: Well �+- - Total length/size ! �.-s7_' Foundation / Property Line SEEPAGE PiTS Depth Size �� SUMPS Number ❑ Distance to nearest: Well ` .� Foundation �"`�'Property`'L'ine_ `' 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 District. ` y Home owner or licensed agent's signature certifies the follin em ploy an � ow9: "I certify that in the performance of the work fog which this permit is issued, I shall.not P Y y 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 em to arson§'subject to workman's compensa- tion. 1 tion.laws of California." �P Y p� � pe The applicant- c f all required inspections. Complete drawing on reverse side: n Signed Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date 1 Area sib r: Pit or Grout Inspection by Date Final In 4 pI? spection b Date lc� d lI A 'tional Comments: tk 466-6781 ❑ Lodi 369-3621, ❑ Manteca 823-7104 ❑ Tracy 835-6385 A plicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I� FEE AMOUNT DUE CK INFO AMOUNT REMITTED CASH RECEIVED BY DATE EEF '-I NO. + EH 1374(HEV,i/a5) I; EH 1428 Q�� _`2 r