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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 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 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.,q 1-713 Job Address i l bCity Lot Size PM Owner's Name w Address 1 Q Phone r /' ��jj Contrac ress t -u``7�e7 License NaJ9 - Phone '0+ ' TYPE OF WELL/PUMP: JF f NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 3 PUMP`INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ t` DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE t TYPE OF.-WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t ❑ Industrial ; ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing {t ❑ Domestic/Private 1 ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1"1 Public 5 Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done 'O Type of Pump H.P. State Work Done ' Well Destruction ❑ Well Diameter Sealing Material (top 591 Depth Filler Material (Below 50'1 v r TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I I fNo septic system permitted if public sewer is C7 ? — --- - 4 /_� available within 200 feet.) ( Installation will serve: Residence— Commercial Other t W E Number of living units: -/—'-Number of- edroom" Character of soil'to a depth of 3-feet: _ t Water table depth W SEPTIC TANK ❑ Type/Mfg ,r Capacity - No. Compartments PKG. TREATMENT PLT. ❑ L " - -� Method of Disposaj Distance to nearest: Well Foundation Property Line LEACHING-LINE ❑ �No.'&.Le gth.of lines Total length/size FILTER .BED k I] Distance to nearest: Well'. t Foundation Property Line SEEPAGE PITS Depth.,` Size fVeumber Ar + SUMPS L1 Distance'to nearest: Well ��..-# .Foundation Property Line 4 DISPOSAL'�O.ONDS e ❑ I hereby certify that i have prepared this appli ation and that the work will be done in accordance with San Joaquin cou nty'ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the fdllowing:s"I certify thbt,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 call forQ�-qu r inspections. Complete drawing on reverse d I Niii Signed X Title: Date lell A _ r �TFtJR DEPARTMENT USE ONLY Application Accepted'tiy ;�Data t ,,' �,t Pit or Grout Inspection by Date l fr &,Final Inspection by 7( Date. Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 ? Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 { ,4 FEE INFO - AMOUNT DUE AMOUNT REMITTED CA K RECEIVED BY DATE PERMIT'N0. a.EH 13-24(REV.i/A 51 1 � I EH 14-26 �