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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE.T ON AVE., STOCKTON, CA y Telephone (209) 466-6781 ;PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) A lication is hereby made to the San J lquin Local Health District for a permit to construct and/or install the work herein described. This application is PP made in compliance.with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welUpump and the Rules and Regulations of the San Joaquin Local Health District. ' C- Job Address City { Lot Size PM 7 Owner's Name 1 Address r �� Phone Contractor + Address /�� License No.� �� Phone TYPE OF WELLIPVV,. NEW WELL WELL REPLACEMENT ElDESTRUCTION El PUMP INSTALLAT�IO1�N, ❑ . SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK. Gv 7FSEWER LINES DISPOSAL FLDI+�(91 PROP. LINE+ e 10 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS/ INTENDED USE TYPE ELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ? r` 11 Industrial Open.Bottom [J Manteca Dia. of Well Excavation Dia. of Well Casing jlk,Domestic/Private-, 13Gravel Pack C3Tracy Type of Casing Specifications M Public n Other ❑ Delta Depth of Grout Seal Type of Grout r/►��,�_. ' I I irrigation --Approx. Depth I 1 Eastern Surface Seal installed by E Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter 13,x. Sealing Material Itop 50'1 ,Depth , 0L _-- Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l i DESTRUCTION l 1 INo septic system permitted if public sewer is f 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 f� SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ' 17 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I. 1 Depth f Size _ Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I 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 pars in such manner as.to become subject to workman's compensation laws of California." Contractor's hiring or sub contracting signature certifies the fo11 wi g: "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 C lif nia." r The applica _ford re uired in pections. Complete drawing on reverse side. /�p --f> AOZ Signed Title: I .�+ �C/t.ol�/[� ' ' Date: FOR DEPARTMENT USE ONLY Application Accepted by ' Date Area" Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 - ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1661,E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 3 5EEy5ry/AMOUNT DUE t AMOUNT REMITTED GASH RECEIVED BY f DATE PERMIT'NO.. I IMM+.EH 13-24(REV.1 i x 5) EH 1428