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c 1 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA ` Telephone (209) 466-5781 PERMIT,EXPIRES 1 YEAR FROM DATE ISSUED ' (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 z5- made in compliance with Sari 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. r e• Job Address 7 CttY� C-` tkot Size PM i Owner's Name —�, S� Address �� ^� �� Phone } t f Contractor Address License No. -10 7 Phone �✓ ' ` �� ' OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ "3 DESTRUCTION -T PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHE ❑ 1` DISTANCE TO NEARES TIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDA AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PRO REA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca of'Well Excavation t Dia. of Well Casing r ❑ Domestic/Private ,❑ Gravel Pack ❑ Tracy Type of Ca Specifications W ! Ll Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation J4pprox. Depth ❑ Eastern '"`Surface Seal Installed by a State Work Done Repair,Work Done ❑ .Type of Pump H.P. � Well Destruction ❑ Well Diameter Sealing Material atop 501, Depth Filler Material (Below 50'! TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO iNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms 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 l5- FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth I Size Number SUMPS El Distance to nearest: Well Foundation Property Line DISPOSAL PONDS - d -4 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." Contractors 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 alifornia." ' The applic n ust call for al quired inspections. Complete drawing on reverse side. t o Signed Title: Date: FOR DEPARTMENT USE ONLY I Application Accepted Date �� Area 03 -- Pit or Grout Inspection by Date Final Inspection by Date ted~ Additional Comments- ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 ► Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O..Box 2009, Stk., CA 955201 FEE AMOUNT DUE AMOUNT REMITTEDINFO NSASW RECEIVED BY DATE PERMIT'NO. + EH 13-141REV.t/asl 3 t CLQ- k �� QUO `�V'A EH 14.18