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APP`UCATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA ReTelephone (209) 466-6781 "` r� 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� 1�-fi!�:P %Ir€? _ City o -rat Size PM Owner's Name ..Il�tt' (�.r &/ 4r-%— Address Phone Contractor L Address �! �� 6e License No. / 0 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR W OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom © Manteca Dia. of Well Excavation Dia. of Well Casing I5CDomestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications 17 Public n Other F1 Delta Depth of Grout Seal Type of Grout _ I I Irrigation _.Approx. De th 4 1 Eastern Su ce Seal Installed b Repair Work Done (;9 Type of Pump _ H.P. State Work Done G. Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material IBelow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION l'1 REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal f I 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 l I Depth Size Number SUMPS 0 Distance to nearest: Well Foundation Property Line 75 DISPOSAL PONOS ❑ 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 DEtrict. 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 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 permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant In all for all r quired ins ctions. omplete drawingo reverse so e. f/ Signed `� Title: _ 5 Date: `�u FORD TMENT USE ONLY Application Accepted by Date 7 re �J Pit or Grout Inspection by Data Final Inspection by Data Additional Comments: 0 Stk 466-6781 ❑ Lodi 369-3621 D 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. +.EH 13-24(REV.vix5f � EH 14-2e