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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone {209} 466-6781 PERMIT EXPIRES '{"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, r f Job Address /U__cp �3 //su,rQ/'� It (.� City J_�Z:S_C_92 Lot Size "�Oi�� PM XOwner's 1 5 a �e Address b AM 4 Phone Contractor Address /' License No, �,_�phone ' TYPE OF WELL/ MP:" w NEW WELL,❑ r -WELL REPLAC T•❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TAMC SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS (t, INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS V1 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation' Dia. of Well Casing . C' ,;. ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications S f"1 Public Ll Other i ❑ pelta Depth of Grout Seal Type of Grout _ V' I 1 Irrigation —..Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done Ll Type of Pump H.P, State Work Hone Well Destruction C] Well Diameter Sealing Material ltop.50') + Depth .( Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I i � DESTRUCTION if iNo septic system permitted public sewer is vailable within 200 feet.l Installation will serve: Residence t Commercial— Other Number of living units: Number of bedrooms --Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments -Pk-G,TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line � I LEACHING LINE ❑ »No. & Length of lines Total length/size =�FILTER BED " D Distance t0 nearest: Well Foundation Property Line • t SEEPAGE PITS I 1 Depth Size Number SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 L rules and regulations of the San Joaquin.Local Health Diktrict. 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 compansa- tion.laws of California." The applicant must call for all r ired i ctions. Complete drawing,on reverse side. (�' Signed Title: ® rte` Date: Ir-19—fl FOR DEPARTMENT USE ONLY Application Accepted by Date Area_! Pit or Grout Inspection by Date Final Ins p pn by Date r Additional Comments: N Y � Q Stk 466-6781 ❑ Lodi 369-3621'- C1 Manteca 823-7104 C7 Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CIC RECEIVED BY INFO d DATE PERMIT'NO. +.EH 13-24{REV.v i x 51