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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON 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. " 7 QY.S� �. City0440 Ch Lot Size PM Job Address Owner's Name H � f� U hrF Phone 3 / o r Address S' ,7if 2 Contractor Addfess License No. Phone_ v TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ p }- 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 'PROBLEMAREA " CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom,. 1' ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy " i iType of Casing Specifications. ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation __--Approx. Depth ❑ Eastern Surface Seal Installed by J Repair Work Done LJType of Pump H.P. ! State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') ' Depth FilleF Material (Below'501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑1 REPAIR/ADDITIONDESTRUCTION O (No septic system permitted if public sewer is \, available within 200 feet.) Installation will serve: Residence_f Commercial— Other i Number of living units: ' Number of bedrooms- Character of soil to a depth of 3 feet: �-/ IF 4 _Water table depth SEPTIC TANK ElType/Mfg+' �` �" Capacity J.?00 5�4, No. Compartments PKG. TREATMENT PLT. ❑ Y> t. t� ►a f 1 ` Method of Disposal -Distance,to nearest: r" Well _ Foundation 26 Property Line 3,3 LEACHING LINE No. & Length of lines Rtal length`/size E, f�"Property Line S t' FILTER BED ❑ Distance to nearest: Well�_ Foundation SEEPAGE PITS X Depth Size umber ;{ i SUMPS L1Distance to nearest. Well Foundation 16-P Property Line DISPOSAL PONDS ❑ i C ! 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. l , 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." . i The applicant mtot call for all re fired inspections. o late drawing on reverse side. Signed X!Y�-� d"�U`� iu STitie: Date: ••3 ] + i �/Y FOR DEPARTMENT USE ONLY r*9 / nApplicat�Accepte by Date Area&it Grout Inspection by Date � . mal Inspection by �"" Date .. fry Additional Comments: ❑ Stk 466-6781Lodi 369-3621 L1Manteca 823-7104 ❑ Tracy 835-6385 " Applicant- Return all opies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ,N i ( FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO v/ r- + + EH 13-24(REV.t i x5) 3 Ll �/ 4 r��r'"'` �5��• �J EH 1428