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APPLICATION FOR PERMIT - = 1 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA 7 Telephone (209) 466-6781 (PERMIT EXPIRES TYEAR FROM DATE ISSUED 1 (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. n � Job Address 7 '- y City r of Size Le'/� �-�'M r 1 Owner's Name �/ Address fn _ Phone Contractor L- ddress W i" License No,Y,0 2l Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ F DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE--TWE OF WELL PAOB'�EM AREA _CONSTRU(fTION'SPECIFICATIONS I ❑ Industrial--4----^------1=)-Open-Bottom-y —O Mahteca—.Dia-.of-Well-Excavation-_ Dia. of Well Casing Domestic/Private )V Gravel Pack _❑ Tracy Type of Casing-----,-- .Specifications N ; F] Public F] OtherI ;71 Delta Depth of Grout Seal �_� S _ Type of Grout 1 i Irrigation F 2�_Approx. Depth "'1 I Eastern W. Surface Seal Installed by - r Repair Work Done 113 Type of Pump } H.P. �� State Work Done_ Well Destruction ❑ Well Diameter "9 . Sealing Material (top 501 Depth f " Filler Material (Below 50'1 -- TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION ! I DESTRUCTION i I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial— Other nY. 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 1 PKG. TREATMENT PLT. ❑ F Method of Disposal Distance to nearest: Well Foundation Property Line �� I I r Total len th/size +' LEACHING LINE ❑ No. & Length of lines 9 FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I ) Depth I Size Number - I SUMPS ❑ Distance ito nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I 1 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 Di1trict. 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 hcertifies the fallowing: "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." •' i The applicant must call for all required inspections. Complete drawing on reverse side. 1 { Signed Title: / ��/ Date: i FOR DEPARTMENT USE ONLY ' Application Accepted by Date t t iz Area Pit or Grout Inspection by I Date Fina-ll Inspection by J/� Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ M nteca 823-7104 ❑ Tracy 835-6385 Awl/Ir Applicant_;.,Return all copies to: E vironmental ealth Permit/Services 1 1 E Ha Iton Ave., P.O. Box 2009, Stk., CA 952 ,1 4k � W Z F—FEE7 AMOUNT'DUEj AMOUNT REMITTED RECEIVED BY DATE PERMI'r'NO. r� INFO : _ s t +,EH 13.24 IREV.1/N 51 A, EH y �� Q EH 1428 ' - .. 7�q