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APPLICATION,FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE, STOCKTON, CA Telephone '(2091 466-6781 PERMIT EXPIRES1 YEAR FROM DATEISSUED s 1 {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 de cribed. This application is made in compliance with San Joaquin County Ordinance No:549 for sewage or�No. 1862 for well/pump and the Rules a Local Health District. nd Regulations of the San Joaquin 9. j Job Address �� ' yi g •r> w,� w �r.� r Q — City &-!�Size PM Owner's Name r 111`�C3 �T Address ��- � - � - Phone - �T t Contractors �_60License Na O Phone a- TYPE OF WELL/PUMP: INEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR " OTHER LJa DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ 4 INTENDED USE TYPE'OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 'Ll Industrial ---------Open Bottom C7 Manteca Dia. of Well Excavation- Dia. of Well Casing x Domestic/Private LJ Gravel Pack L1Tracy Type of Casing Specifications i ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done `! Type of Pump _ H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material.(Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 4 available within 200 feet.) Installation will serve: Residence w Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. E1 �+ �_ „f Method of Disposal Distance"to nearest:.',"Well Foundation Property Line LEACHING LINE No. & Ce'ngth of line's""""' --- -Total length/size r FILTER BED ❑ Distance to nearest; Well Foundafi6ri1,'. Property Line �.4 ? SEEPAGE PITS F1' Depth I Size! f 1_1< Number .1 ,r SUMPS .❑+ Distance to nearest:_ -Well -.' Foundation 1 Propertty line°�-'dt� DISPOSAL PONDS " ❑ y=_y I hereby certify that 1 have prepared this application and that the work will:be_done in'accordance with San,Joaquin county ordinances, state laws, and i t rules and regulations of the San Joaquin` acal 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 empEoy persons subject to workman's compensa- tion laws of California." The ap m t call for all r red�ins ions. C plate drawing o verse side. Signed Title: Date: FOR DEPARTMENT USE ONLY 0�f Application Accepted by r/ Date —(0 Area Pit or Grout inspection y Date Final Inspection by Datee Additional Comments: i ID Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 , l Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2004, Stk., CA 95201 FEE , ,y.AMOUNT DUE "= C AMOUNT"REMITTED CK rf INFO CASH RECEIVED BY DATE PERMIT"NO. 4 + EH 13-24 4REV. EM 14-215 L . .. .. - :.J- H way 4w. A• > ..� ... [ l