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J APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 1 ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED 4' (Complete in Triplicate) r 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 o.549 for sewage or No. 1862 for well/pump-and gthe Rules and Regulations of the San Joaquin made in compliance with.San Joaquin County Ordinance N Local Health District. t,-7 -� City Lot Size PM ' Job Address t+- 1� �D. , r Address Phone Owner's Name 2 �.; License N_o..& .Phone Contractor Address TYPE OF WELL/PUMP: -"NEW WELL F1 WELL REPLACEMENT 1-1DESTRUCTIONJ PUMP INSTALLATION 11SYSTEM REPAIR FI OTHER L3 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION" AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing ❑ Industrial ❑ Open Bottom L1Manteca Dia. of Well Excavation Specifications omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing - F1 1 Delta Depth of Grout Seal kType of Grout i f"] Public ( Other - l[ -l Surface Seal Installed b I i Irrigation =A�PtoxrDepth--1 I Eastern---� _ _ y- r H p State Work bone '• Repair Work Done 1 D Type of Pump -x- - Well Destruction Well Diameter .— Sealing Material (top 541 G ` Depth T 9� — Filler Material /Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I.1 REPAIR/ADDITION I i DESTRUCTION l 1 septic system permitted if public sewer is ave p - available within 200 feet.? Inst911ation will ser4ve: Residence't Commercial Other !Number of living units: Number of bedrooms Character of soil to a depth of 3 feet : Water table depth SEPTIC TANK F] Type/MfgCapacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal i iDistance to nearest: Well Foundation Property Line;-4 LEACHING LINE ! ❑ No. & Length of lines Total length/size ^� FILTER BED I ElDistance-ta nearest: Well Foundation Property Line (�/ k 1 u _ 1 Number k SEEPAGE PITS i I Depth Size ; SUMPS L1 Distance to nearest: Well Foundation" Property Line 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. Homejowner or licensed agent's signature certifies the following: "1 certify that- the"performance of the work for which this permit is issued, I shall not empkby any parson 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 performanceofthe work for'which tai s permit isiiss 4 ed, I shall employ persons subject to workman's compensa- tion lavas of California." r 1, r! The applicant II requ' ctions. C,arnplete drawing on r rso Ide: t Signed Title:'r` Date: - �- �P�AR5TIMENT E ONLY - -- AppjicationAcceptedby _Date -j— _Area_ - Pit or Grout Inspection by Date1� ' Final Inspection by Date I Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 _.Applicant_Retum-Wi.copies-toz-Environmental.•Health-PermiN•Services-x603-1r--Hazetton-Ave�-0-B'OX-2009-51k reA-95201 - FEE MOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT•NO. � INFO/ + EH 13-24(REV.1/H 51 S .DD EH 14-26