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a F APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE iON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i. . (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.. f,y X13 � r 4 ` I a' ' City �t Lot Size PM ' Job Address !I„ ,p Owner's Nam �' :`� ` ress Phone q514 ak5 Contractor's Nam ( IEaC License No."I �p '% Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 'K` il PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK t SEWER LINES, -- DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICAT10 S 11 Industrial ❑ Open Bottom, ❑ Manteca Dia. of Well Excavation_,6�2 Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout —Approx. Depth ❑ Eastern Surface Seal Installed by ❑ Irrigation —ApP p Repair.Work Dane ❑ Type of Pump I H.P. State Work Done -Well Destruction j Well DiameterI Sealing Material (top 50`1 1`') I Depth Filler Material iBelow 501 TYPE OF SEPTIC WORK:` NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION INo septic system per tted if public sewer is 4{ available within 200 feet.) Installation will serve: Residence I Commercial Other v Number of living units: Number of bedrooms Character of soil to a'depth of 3 feet: E�- Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 71 Property of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ElNo. & Length of lines Total length/size FILTER BED ❑ 'Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS 11Distance to nearest: " " Well Foundation Property Line DISPOSAL PONDS Cl 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. r Home owner or licensed agent's"signature card ies the following: "I certify that in the performance of the work for which this permit is issued, I shall not -oknploy 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 Callforni . The applic t ust all fo all required inspections. Complete drawing on reverse side. Signed T Title: Date: r FOR DEPARTMENT USE ONLY Application Accepted by Date Ce8 d� I Pit or Grout Inspection b ; Date Fin?l inspection by ate I � G�I�J`.: �` M �- ••F' � f /Q n of Additional Comments: 1 rStk 466-6781 ❑ Lodi 359-3621 ❑ 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 AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"NO. INFO CASH t 7 EH ia-24IREv.torso) /1/ �t-t i EH W26 - .yi_•,