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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 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 withrSanrJoaquin,C,_ounty Qrdinance,No 544 ior.sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health©i$tnct r;�'��'W F� _ry1 LN / l�-G1 City tsit Lot Size .� QC`lr PM Job Address ` i/ Address - 62Phone Owner's Name �» Contractor Address CC L' • e icense No. n' Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ .DISTANCE TO NEAREST: SEPTIC TANK _.fes SEWER LINES 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 Domestic/Private KGravel Pack ❑ Tracy Type of Casing I/4� Specifications 1-1 Public n Othyr F) Delta Depth of Grout Seal Type of Grout - I I Irrigation %<�`S.Approx. Depth I. I Eastern Surface Seal Installed by Repair Work Done [IType of Pump H.P. State Work Done Well Destruction ElWell Diameter Sealing Material /top 501 DepthFiller Material IBalow 50'I r TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION l 1 DESTRUCTION l I alvo septic lable withm rented if public sewer is Installation will serve: Residence_ Commercial— Other S Number of living units: Number of bedrooms 6 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property.Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line V SEEPAGE PITS 11 Depth Size Number k• -- SUMPS Ll Distance to nearest: Well Foundation Property Line 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 Di%trict. 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-contracting signature y certifies the fopowing: "I certify that in the,performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa, I tion laws of California." l h The applicant ust call for all requi d inspections. Complete drawing oa re arse side. / \ Signed X Title: < Date: 6 —c ' FOR DEPAR ENT USE ONLY Application Accepted by aN"IIV, — Date Area I Pit ar routnspection by Date Final Inspection by Date ' r Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369.3621 ❑ 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 s _ FEEJMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. SR INFO / � +.EH13-244r1EV.i/n5) f`+ ®� EH 14-26