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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL I ON AVE., STOCKTON, CA Telephone (209) 466-6781 I 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. Job Address Q� � �,r� � City Lot Size PM Owner's Name /� ( Address Phone Q ! Contractor's NameLicense No/"3� Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION D SYSTEM REPAIR Gii�o OTHER ❑ DISTANCE TO-NEAREST-.-'SEPTIC TANKS-"� " ��5EWER LINES =. ==.DISPOSAL FtD.-- - -PR, _. ..� F FOUNDATION L AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing I ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. De ❑ Eastern urface Seal Installed by Repair Work Done L Type of PumpH.P. i State Work Done Well Destruction_ ,r 0_Well.Diameter�1F,.--A 31,�� Sealing..NMaterial (top 50'1_.. Depth Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is .� available within 200 feet.) -_Installation will serve: Residence_ Commercial_ Other ';7 *CNumber-of living units: Number of bedroomst' Character of soil to a depth of 3 feet: 1 Water table depth SEPTIC TANK ❑ Type/Mfg . ;G" Capacity k'f. No. Compartments PKG. TREATMENT.PLT. ❑_ �_,.._.i. ,__ a �-.:„,_--_ .»�- -- �f- ---Method•of-Disposal Distance to nearest: Well Foundation Property Line t LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size ` ' ' kF 'h`'-" a Number ` SUMPS - ` ❑ -'Distanceto nearest:°" Weflr� " '"" Foundation E �� "`Property-Line a DISPOSAL PONDS ❑ 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 person in such manner as to become subject to workman's corripensatiori'laws of California." Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for whicl this.permrt is is ued,I shall employ persons subject to workman's compensa tion laws of California." The applicantmust call for a I r uired inspectia s. Complete drawing,on reverse side. �` Signed 'tle:' � Dater 7 O FOR DEPARTMENT USE ONLY 11 Application Accepted by X<- Date�_��J Area Pit or Grout Inspection by I Date Final Inspection by Date V f i Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I IFEE I NFO AMOUNT DUE I AMOUNT REMITTED CCK 0 RECEIVED BY ` DATE PERMIY'NO. + EH 1324 IREV.10/8315 I EH 14-28 m