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f V . I o ' 7j APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL 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. IB62 for weli/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address City / Lot Size PM 1 Owner's Name ddress Phone �� C ,Contractor / S54NAddr.ss License No. I�Phone J TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I PUMP INSTALLATION ❑' -SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST:4PTIC14"AtNK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS s i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial C Open Bottom ❑ Manteca -Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F1 Public ❑ Other''-'--- —, ❑ Delta Depth of Gout Seal Type of Grout i ii I Irrigation _Apr�xi_l7eth, 1 I Eastern urface Sea Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done ``! /Well Destruction ❑ Well Diameter Sealing Material-atop 50'! Depth -` �—Fill er-Material {Blow 50' 1 � TYPE OF SEPTIC WORK: NEW INSTALLATION�I:1—REPA.IR/ADMTIOK,,#-• DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation'will serve: Residence_ Commercial=1 JOther Number of livor units: Number of bbd oomg Character of soil to a.depth of 3 feet: I i Water table depth a SEPTIC-TANK tiQ Type/Mfg � ,Capacity No. Compartments Cl' PKG. TREATMENT PLT. ❑ i Method of Disposal 7t� Distarice to nearest: Well l Foundation Property Line LEACHING LINE *'-Cl No. & Length of-lines t� I Total length/size FILTER BED Cl ..Distance to nearest�� Well�-i- Foundation Property Line SEEPAGE PITS I 1 Depth Size` _ Number SUMPS L� Distance to nearest: Well I Foundati Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that-thelwork will be done,ip accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health D1%trict. r ''1\Home owner or licensed agent's signature certifies the fallowing: "I (rttt 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 c IN :nsation 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 shlhemploy persons subject to workman's compensa- tion laws of California." The applica r II req tions. Complete drawing on reverse side. Signed X Title: �� ``� Date: OR DEPARTMENT USE ONLY Application Accepted by Date _Arte Pit or Grout Inspection by Date Final Inspection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-63$5 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH + EH 13-241REV.tiK 61 3 �=gyp GGL C-t5 -8y "-),3'Ir EH 14-29