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APPLICATION FOR PERMIT I�' ` �� {" ' SAN JOAQUIN LOCAL HEALTH DISTRICT. SEP U11 1 1601 E. HAZELTON AVE., STOCKTON, CA 1984 Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR.FROM DATE ISSUEDder- i"'I T t a (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. Job Addresscity • Lot Size PM Owner's Name /J/. Address n� l� Phone Contractor's Name +i` License No. A/0 Phone ! TYPE OF WELL/PUMP: NEW WELL El WELL REPLACEMENT ❑ DESTRUCTION C1 PUMP iNSTALLATIIONN k SYSTEM"REPAIR,,❑ OTHER 13 _ \) DISTANCE TO NEAREST: SEPTIC TANK 1152 SEWER LINES i DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing VDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 4 ❑ Public ❑ Othgr ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation A-6-14prox.'Depth ❑ Eastern Surface Seal Installed by Repair Work Done AType of Pump �: 5yLL H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Stop 501 Depth Ho Filler Material (Below 501 ' I TYPE OF SEPTIC WORK: NEW INSTALLATION ❑",REPAIR/ADDITION O DESTRUCTION.E3 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms ; Y Character of soil to a depth of 3 feet:I -t A '" --— i Water table depth SEPTIC TANK ❑ Type/Mfg' -Capacity ` " ^�- ' 4No. Compartments PKG. TREATMENT PLT. ❑ i IMethod of Disposal f � Distance,to nearest: Well Foundation Yroperty Line LEACHING LINE ❑ No. & Length of-lines Total length/size FILTER BED ❑ Distance{to nearest: Well Foundation J < . O-4 Property Line -A_ SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ .Distance�to nearest: Well " - -- --"rFoundation - Property Line DISPOSAL PONDS ❑ i( 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."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 California." The applicant must call for all required insWcVo s. Cc plate drawing on lreverse side. Signed �� ' Title: ®�/ • Date: FOR DEPARTMENT USE ONLY 1� Application Accepted by Date dv Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca t 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 INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT`NO. EH 13-24(REV.10/891 EH 14-28 f