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r APPLICATION FOR PERMIT <";.5 t SAN JOAQUIN LOCAL^HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 qT PERMIT EXPIRES 7 YEAR FROM DATE ISSUED". (Complete,in,Triplicate) r. <. District for a permit to construct and/or install the work herein'described.Thisapplication SanlJoaquin Joaquin Local Health D les and.Regulations of Application is hereby made to the San q made in compliance with San Joaquin County Ordinance No.549 for sewage or No_."1862 for we lilpump and the 4 1 T ' Local Health District. .k?� City Lot Size PM 1 Job Address ,v.1..•V�e-.�e��-,�,�� t �-: Phone �rrwiy ddress �� i Owner's Name Addressl�` y E License No.ytX1, Phone . Contractor DESTRUCTION ❑ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT RE ❑ OTHER 11 PUMP INSTALLATION ❑ SYSTEM"REPAIR ❑ SEWER LINES DISPOSAL FLS. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK - OTHER-WE�L�' PITSISUMPS —: i FOUNDATION- , - -",AGRICULTUREVIELL� . INTENDED USE TYPE OF WELL PROBLEM CONSTRUCTION SPECIFICATIONS Dia. of\IVell Casing ' ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Y Specifications K� ' Type of Casing V l�Domestic/Private ❑ Gravel P k ❑ Tracy YP X51 .. `� (ybe of Grout LD Public ❑ Other ❑ Delta Depth of Grout Seal rt ❑ irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by i f Type of Pum H.P. State Work Done Repair Work Done 1 YP p — \ ' Well Destruction L3 Well Diameter Sealing Material [top 50'1 N Depth I Filler Material (Below 50') \\\ j TYPE OF SEPTIC WORK: NEW INSTALLATION ❑.YRELg,R, f.r,.I rN . DESTRUCTION Otted if public sewer is I avail abPeFwi h within feet.) l Installation will serve: Residence Commercial— Other i {! Number of living units: Number of bedrooms --" I 11 .1 4� ,,+* Water table depth \\ Character of soil to a depth of 3 feet: , a No. Compartments SEPTIC TANK -# ❑ Type/;fg Capacity ii Method of Disposal t PKG. TREATMENT"PLT. ❑ 1 ' Distance to nearest: Well Foundation Property Line ti Total lengthlsize, LEACHING LINE Ll No. &'Length of lines 1; Property Line FILTER BED ❑ Distance to nearest: Well ";Foundation I SEEPAGE PITS ❑ Depth,I f Size k+ Number IFoundation Property Line SUMPSY,- _❑ Distance to nearest: Well DISPOSAL PONDS ❑ F 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, an rules and regulation1. s of the San Joaquin Local Health District. .t ' i 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, ! 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 f tion laws of California." 4 F The applicant must ca for all required inspections. Complete drawinbo reverse side. i .+ Title .tau -•. Date: Signed p FOR DEPARTMENT USE ONLY !Io 7 Date `'� Area i Application Accepted by r Date Final Inspection by Date Pit or Grout Inspection by k Additional Comments: �^ El Stk 466-6781 El Lodi 369-3621 EJ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazekon Ave P.O. Box 2009, Stk., CA 95201 CK# RECEIVED BY DATE ' PERMIT'NO. FEE AMOUNT-DUE AMOUNT REMITTED CASH INFO + EH13241REV.1/est - EH 14-28