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_ r . 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 ;I. (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct andlor install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for weii/pump and the Rules and Regulations of the San Joaquin Local Health District. 1-7"7"7 City Lot Size PM Job Address127-7 337 So one f(W�' Address hone Owner's Name Contractor AddressDL�Pp� yA�l �+- License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ EWER LINES DISTANCE TO NEAREST: SEPTIC TANK S DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL I _OTHER WELL P1TSlSUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Type of Casin T Specifications 'Domestic/Private ❑ Gravel Pack ❑ Tracy g- `; FI Public F Other C-1 Delta Depth of Grout Seal Type of Grout i I Irrigation ..Approx. Depth l I Eastern Surface Steal ( stalled by ,�/ WP_ i State Work Done Repair Work Done Typ_e of Pump �� Well Destruction ❑ Well Diameter Sealing Material (tap 50'1 Depth I Filler Material IBelow 50'! TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is i available within 200 feet.l Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms i � Water table depth Character of soil to a depth'of 3 feet: , -SEPTIC TANK El Type/Mfg. A,Capacity No. Compartments PKG. TREATMENT PLT. ❑ t Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines _ +- Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size _ Number SUMPS Cl Distance to nearest: Well Foundation Property Line !t - DISPOSAL PONDS ❑ I hereby certify that l 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 Di§trict. 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 I employ any person in such manner as to became subject to'v+rorkman'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,l shall employ persons subject to workman's compensa- tion laws of California.'_'_- e} y The applicant must ll for all re wired inspections. Complete drawing on-reverse Signed 7itle:'� Date: )C _ ,• ---- -� .T ,_ „�. ' t R DEPARTMENT USE ONLY Application Accepted by � Date1p Area Pit or Grout Inspection by Date Final inspection by ate s7 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 2009, Stk., CA 95201 E FEE AMOUNT DUE I AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT*NO. INFO —005 ..EH13-241REV.tiik5) EH 14-26