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APPLICATION FOR PERMIT ` SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED f. ' (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. . .1. S 'S- .4k-,e.4&c 2 e-5� Lot Size P Job Address I {' City �" M Owner's Name ! S d R mr sa Phone Contractor Address License No. Phone ' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 e PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS a INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing i j ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other 17 Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx.. Depth C] Eastern Surface Seal Installed by r Repair Work Done Ll Type of Pump t H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material-(Below 50') (A TYPE OF SEPTIC WORK: NEW INSTALLATION EIREPAIR/ADDITION ❑ DESTRUCTIO No septic system permitted if public sewer is (� j I available within 200 feet.) Installation will serve: Residence_ Commerc ial— Other I Number of living units: Number of bedrooms Tom' Character of soil to a depth of 3 feet: s ._„ Water table depth SEPTIC TANK 11Type/Mfg i Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal i `--' ""Distance to nearest:' Well Foundation Property Line 1 i LEACHING LINE ❑ No. & Length of lines 4 Total length/size t FILTER BED ❑ Distance-to nearest: Well Foundation Property Line I SEEPAGE PITS C1 Depth Size Number I I SUMPS - ❑ Distance to nearest: Well -foundation-- Property-Line ` 1 ' 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. 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."Contractors hiring or sub-contrasting 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." I - ,. sa- The applican all for all required inspections:-Complete'drawing on r verse side. f Signed X d142if � Title: r Date: FOR DEPARTMENT USE ONLY i Application Accepted by Date r I i Area I } Pit or Grout Inspection by ! Date Final Inspection by Date b _ 1 - 0,2 Additional Comments: fo rZ E ow ❑ Stk 466-6781 ❑ Lodi 369-3921 ❑ Manteca 823-7104 . ❑ Tracy 8354 E 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 C RECEIVED BY DATE PERMIT NO. + EH 13-241REV.1/e5) / EH 14-288 S- 0 53