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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 TYEAR FROM DATE ISSUED PAYMEUT (Complete in Triplicate) RECEIVED i Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein yfr ry'bed�Ta is made in compliance with San Joaquin County Ordinance.No. 549;for,sewage or No. 1862 for well/pump and the Rules and R jyg ons A Joaquin Local Health a k NVIRONME NTAI HEALTR . City Lot Size — Job Address . I Owner's Name Address �T77, �J' �� Q�r '�'� Phone Contractor Address e No. 4LiZ2/ Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK __l�s�—..-- SEWER LINES DISPOSAL FLD.J�_"_ PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF,WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r1 ❑ Industrial ❑ Open Bottom © Manteca Dia. of Well Excavation /.� Dia. of Wel! Casing Domestic/Private Gravel Pack '� Tracy Type of Casing �Ut1 Specifications 17 Public F1 Other 171 Delta Depth of Grout Seal , Type of ut a . I I Irrigation —.-Approx. Depth ( I Eastern Surface Seal Installed by Repair Work Done Ll Type of Pump H.P. State Work Done _ k Weil Destruction ❑ Well Diameter Sealing Material (top 50') !—{ Depth Filler Material (Below 501 — �f TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION l I DESTRUCTION l I INo septic system permitted it public sewer is .a available within 200 feet.I r 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 PK G. TREATMENT PLT. ❑ Method of Disposal ! t Distances to nearest' Wel! Foundation Property Line j LEACHING LINE ❑ No. & Length of lines Total length/size s FILTER BED ❑ Distance to nearest: Well Foundation Property Line rl . SEEPAGE PITS I 1 Depth I Size Number SUMPS ❑ 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 I rules and regulations of the San Joaquin Local Health District. } 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 become subject to workman's compensation laws of California."Contractors 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 10 workman's compensa- tion laws of California." i ;} The appli ant At call for all requi inspections. Com late drawing o r vers side Signed X Title: Date: 1-41-29 OR DEPARTMENT USE N7_Y Application Accepted by Date Area I t I Pit or Grout Inspection by Date Final inspection by Date tr Additional Comments: k ❑ Stk 466-6781 .❑ Lodi 369-3611 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to.Znvironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED K R RECEIVED BY DATE PERMIT'NO. - INFO *.EH 13-241REV.1/n51 Q ^ EH 14-28