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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 r (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. SA7 .f Job Address r ._ City �_�� Lot Size Owner'sjName Address ✓ - Phone 2 Cl k 7 .! Contractor Address�8� _ r ��U License No ' Phone TYPE OF WELL PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE .� N FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED US.E TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I ❑ Industrial ❑ Open Bottom 1, ❑ Manteca Dia. of Well Excavation {_' pia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing p Specifications ❑ Public �' ❑ Other ❑ Delta Depth of Grout Seal Type of Grout V ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump i H.P. State Work Done $ \j Well Destruction ❑ Well Diameter Sealing Material (top 50'1 j Depth t Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION E] REPAIR/ADDITION DESTRUCTION 11 (No septic system permitted if public sewer is t ' available within 200 feet.) Installation will serve: ResidenceCommercial_ Other '�- F Number of living units:--.._ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity r No. Compartments i PKG. TREATMENT PLT. ❑ Method of Disposal,;_. Distance to nearest: Well Foundation Property Line LEACHING LINE 111 f lines dICJ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest:t Well Foundation " '�Pr`opei'ty Line t t ,t - <, � .. SEEPAGE PITS �71.'5' '6Wpth f'' `` Size g _j - Number SUMPS t ❑ Distance to nearest: Well Foundation Pr"operty 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 j rules and regulations of the San Joaquin Local Health District. 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, I shall not " t 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." '-t1Z. The applicant must caU for all required inactions Complete drawing on reverse side. Signed XL Title: -f Date: FOR DEPARTMENT USE ONLY 'IfAler A5 Application Accepted by ) Date 71&A Area Pit or Grout Inspection by "Date r' �- Final Inspection by r Date Additional Comments; # ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 523-7104 ❑ Tracy 835-6385 Applicant'- Return all copies to. Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO.. AMOUNT DUE T AMOUNT /R'')EMMIy)TTED„ CAK RECEIVED BY DATE PERMIT`NO. + EH142g{REV.1/851 - S LIS--lf'v