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a APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT i 1601 E. HAZELTON AVE_ STOCKTON, CA 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. I�- Lot Size Job Address � �..— City. - - Owner's Name Address Phone Contractor" Address�f I YyI1-5011 LicEnse No. Phon TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION d .x " PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ -: DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL-FLD. PROP,.LINE'} FOUNDATION AGRICULTURE WELL OTHER WELL - PITS/SUMPS' INTENDED USE TYPE OF WELL PR08LEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial D Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing D Domestic/Private ❑ Gravel Pack D Tracy Type of Casing Specifications f-I Public Cl Other F1 Delta Depth of Grout Seal Type of Grout I I Irrigation.. —.-Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50`) TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet.) _ Installation will serve: Residence Commercial_ Other � ��--��}�A Number of living units: _J_ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth 0 SEPTIC TANK . Type/Mfg r� L Capacity Z� No..Compartments r PKG. TREATMENT PLT. ❑ / Method of Disposal Distance to nearest: Well-En -]P—_ Foundation Property Line /0! LEACHING LINE D No.�& Length of lines 0901K/ C= Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line Q f SEEPAGE PITS l I Depth: 'maize _ Number s SUMPS ❑ Distance to nearest: Well Foundation Property Line 1 DISPOSAL PONDS El 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-Di$trict: µ' 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 require in ctions. Comple drawing �rtl@verse side. c Signed X �' Title: Date: 2. " F EPARTMENT USE.Of11LY Application Accepted by A"A&__ ..HCl. Data Area Pit or Grout Inspection by Date Final Inspection by Date CEJ Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca104 , ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 20W, Stk., CA 95201 INFO FEE AMOUNT DUE AMOUNT REMITTED C/ASH RECEIVED BY a' DATE/ PERMIT NO. i EEH 13-24'H t4-28 1REV.1 R 5) [ LL/CT