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APPLICATION FOR PERMIT x SAN JOAQUIN LOCAL HEALTH DISTRICT ; 1601 E. HAZEILTON AVE., STOCKTON, CA r Telephone (Zpg) 466-6781 ' , PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) fA j/ F(,— 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 Regulatio of the San Joaquin Local Health District. Job Address �� City Lot Size PM Owner's Name _ T Phone •' Contractor ddress (/v se No. Phone Q I r TYPE OF WELL PU *r NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUC ON PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK'-_1 SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS k �v INTENDED USE x ITYPE OF WELL , PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial •❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ,. �❑ Other ❑ Delta Depth of Grout Seal Type of Grout F ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by �! Repair Work Done 'f 0, -t Type of Pump H.P. State Work Done AW-11 Destruction 0 Well Diameter Sealing Material (top 501 ` Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION_ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other .r Number of living units: =. ___. Number of bed ms Character of soil to a depth of 3 feet. Water table depth 0 y SEPTIC TANK � Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ -F � Method of D,iissppsal r Distance to nearest: Well Foundation i Property Line—� ' LEACHING LONE ❑ ' No. & Length of lines Total length/size f FILTER BED El .Distance to nearest: Well Foundation /�1 Property Line D SEEPAGE PITS A,Depth Size a.3 i Number SUMPS ❑ Distance to nearest: Well Foundation PITO Property Line d 1 DISPOSAL PONDS ❑ 1 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 1 rules and regulations of the San Joaquin Local Health District. _ � Home owner or licensed agent's signature certifies the following: "I certify th"at 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."Contractors 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." 4 The applicant ust o all re Ire spections. Complete drawing a v rse side. �7j Signed c- l Title: t�CP�7Y! + �–"� Date: FOR DEPART NT USE ONLY Application Accepted by AA Date a Pit r Grout Inspection by Date j l— Final Inspection by Date fi! Additional Comments; r•' ❑ Stk 466-6781 ❑ Lodi "369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354M %,Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t INFO AMOUNT DUE AMOUNT REMITTED CA5H RECEIVED BY y DATE PERMIT'No. + EH 13-241REV.1/e5Y EH 1426