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APPLICATION FOR PERMIT ' e SAN JOAQUIN LOCAL HEALTH DISTRICT C' x 1601 E. HAZEL T ON AVE., STOCKTON, CA j 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. G � � �CJ�U./ a'�J+ - Lot Siz ft PM Job Address City ,y+ r 1Q� M�'i>,+'u' �� O 10,0 r vT Owner's Name _ Address Phone s Contractor _ Address License No. Phone TYPE OF WELL/PUMP: �_ NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ex PUMP INSTALLATION I]1 "x E' SYSTEM REPAIR ❑ OTHER ❑ #DISTANCE TO NEAREST' SEPTIC TANK I SEWER LINES. DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 6,11 ❑ Industrial .,- ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. f Well Casing :`❑ Domestic/Private Ll Gravel Pack ❑,Tracy,„,p--. Type of Casing Specifications F ❑ Public ❑ Other ,❑ Delta Depth of Grout Seal Type of Grout i❑ Irrigation k ---Approx. Depth.`❑ Eastern I Surface Seal installed by Repair Work Done ❑ Type of Pump;`L H.P. ' State Work Done Well Destruction ❑ Well Diameter' "z" Sealing Material (top 501 Depth Filler Material (Below 50'1 r STYPE OF SEPTIC WORK: NEW I N REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is _ r 5 available within 200 feet) x Installation will serve: idence ommercial Othe *)' Number of living units: f Number of edrooms � ,t�OCharacter of soil to a depth of 3'feet: Ow r Water table depth �~ SEPTIC TANK XType/Mfg Capacity( 0 No. Compartments 9 PKG. TREATMENT PLT. ❑ s j Method of Disposal t Distance to nearest: Well Foundation°" Property Line LEACHING LINE No. & Length of lines r ; Total length/size ] FILTER BED ❑ Distance to nearest: WeiI foundation Property Line v� SEEPAGE PITS - f Depth Size Number SUMPS 1-1 Distance to nearest: Well _ = Foundation t Property Line uw� DISPOSAL PONDS El I hereby certify that V 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."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 must call for all required inspections. Com lata drawing on reverse side. / Signed X Title: Date: rv' FOR DEPARTMENT USE ONLY Application Accepted byDate Area -ANr Pit or Grout Inspection by Dae Final Inspection by Date l Additional Comm ' Stk 466-6781 ❑ Lodi 1 1 ❑ Manteca 6 823 7104 ❑ Tracy 835-63$5 App is nt- Return all copies to: Environmental Health.Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE; PERM4T•NO. f INFO CASH I + EH 13-24(REV.i/s sl EH 14-28