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k.' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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. f Job Address �.�- Cit �(J i PM i { i. Y of Size Owner's Name,! J✓ Address _ Phone cs c l r 5 Contractor 442 ovir Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ ' WELL REPLACEMENT ❑ DESTRUCTION ❑ f PUMP INSTALLATI N ❑ SYSTEM REPAIR El OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK I _ SEWER LINES-- =DISPOSAL'FLD.. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 I INTENDED USE TYPE 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 i ❑ Public ❑ Other ❑ Delta' Depth of Grout Seal Type of Groutt4 ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed.by Repair Work Done ❑ Type of Pump H.P. FState Work Done_ W Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION Wo septic system permitted if public sewer is available within 200 feet.] Installation will serve: Residence�Commercial_ Other Number of living units: Number of bedrooms i Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines _ Total.length/size j FILTER BED El Distance to nearest: Well Foundation n Property Line 11 SEEPAGE PITS ❑ Depth Size Number t 4 SUMPS ❑ Distance to nearest: Well Foundation Property Line 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 compensation laws of California." Contractor's hiring or sub-contracting signature I certifies the following: '9 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 must call for all re wired inspections. Complete drawing on reverse side. M } t � N Signed X Title:411- Date: FOR DEPARTMENT USE ONLY' �! G✓� Z-� Application Accepted by Date Area Pit or Grout Inspection by / Date Final Inspectionby Date ditional Comments: c` �e� 01�1 C Cp-. (� v f� �.�.►�.� Stk 466-6781 ❑ Lodi 369-3621 - ❑ Manteca -7104 1 ❑ Tracy 838L6385 A plicant- Return all copies to: Environmental Health Permit/Services,1601 E. Hazelton Ave., P.O.' Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE : AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. + EH 13-24(F1 EV.11x15) Z-00 y tt E14 14-29 ,_ •�' �Z J b