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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 fPERMIT EXPIRES TYEAR FROM DATE ISSUED i (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 ounty Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin made in compliance with San Joaquin C Local Health District. j - ��jj It//tr t9y Job AddressCity Lot Size�✓x L. - PM �l:/� f Z_ gPhone { Owner's Names�-�"� - f�l��ddress __A Wf ��„-,'~-fI _ Contractor " Addtes 1 License No. Phone TYPE OF WELLIPUMP: NEW WELL 1-1WELLREPLACEMENT DESTRUCTION ❑ 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 PROBLEM AREA CONSTRUCTION SPECIFICATIONS 11 Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 171 Public F] Other ❑ Delta Depth of Grout Sea{ Type of Grout - I I Irrigation ;Approx..Depth 11 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 r Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION DESTRUCTION l I (No septic system permitted if public sewer is �1 available within 200 feet.) installation will serve: Residence Commercial_ Other Number of living units: _J__ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments r PKG. TREATMENT PLT, 1-1f Method of Disposal Distance to nearest: Well Foundation Property Line tTot length/size LEACHING LINE No. & Length of lines 4 FILTER BED L) �Distance to nearest: Well FoundatiorhProperty tine SEEPAGE PITS Depth Size__ Number `�— SUMPS Ll Distance to nearest: Well foundation Property Line ' _ DISPOSAL PONDS ❑ 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 r rules and regulations of the San Joaquin Local Health Di%trict. r 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 I The applicant must call for all required i pect ns. Complat drawing on reverse side. ~ 91 • Datev6n k Signed Title: R DEPARTMENT USE ONLY Application Accepted by r .rA M ` Date,,t Area Pit or Grout Inspection by Date Final Inspection by Date d Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ 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 CK RECEIVED BY DATE PERMITNO. INFO +.EH 13.241REV.1/1151 -EH 14-2$