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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 (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 ity Lot"Size Owner's Name � 4dress Phon vit— Contractor s ddressUgy icense No. Ph . TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. Z PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL`^ PITS/SUMPS INTENDED USE �f�TYPE QF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS---- ❑ Industrial ❑ldpeIlBottom N- -.y❑ Mantec'a-a { -\ D`. Well Excavation Dia. of Well Casing ❑ Domestic/.Private,_.._O_Gravel_P_ack ❑.Tracy Type�of.Casing _ Specifications � f l Public f-1 Other ❑ Delta Depth of Grout Seal Type of Grout I I'irrigation ..Approx. Depth I I Eastern Surface Seal Installed by _ Repai'L.Work Done ❑. Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50') t ,� Depth Filler-Material- elow-50'-1— TYPE-OF SEPTIC WORK: NEW INSTALLATION i I REPAIR IADDITIO f',AESTRUCTION I I (No septic.system permitted if public sewer is I 3 available Within 200 feet.) t "nstallatipn will serve Residence_ Commercial— Other. (,Number I i of livino,drits: 1 Number of bedrooms r,�..�,,dt r f h l Cz�acter of soil to a depth of 3 feet: i F f Water table depth SEPTIC TANK ❑ Type/Mfg y Capaciy — No. Compartments 1 «�� PKG. TREATMENTPLT..❑ t t Methodipf Disposal Distance to nearest: Well `�`�Foundation ?Property Line LEACHING LINE ❑ No. & Length of lines ^ Total(length/size- or- FILTER BED D. Distance to nearrest: Well ITAI undation - =rProperty Line SEEPAGE PITS l I''r'Depfh'�� Size Number SUMPS 0 Distance to nearest: Well Q Foundation Property Line DISPOSAL PONDS Ell s i I hereby certify that I have prepared thisplication and'that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Ldcal Health Diltrict. Home owner or licensed agent's signature,certifies-fhe 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 cf the work forwhich this permit is issued, I shall emplayj'persons subject to workman's compensa- tion laws of California." The applica must ll for all re a re' pecti s. Complete drawing on reverse side. 4 Signed X Tide: Date: x FOR DEPARTMENT USE ONLY f Application Accepted by Date. Area 0itr Grout Inspection b Date_� f d Final Inspection by Date( Additional Comments: ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services.1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEV. INFO AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT`NO. 13-24 V.tik5i o �v Y/s �, ./ * EH 10-26 l PE r ' I