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l APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED. 5-r t y;; (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 62 made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 18for well/pump and the Rules and Regulations of the San Joaquin Local Health District. %.�rof' " Job Address _Z �'y r� '� +^ C'tY ""Lot Size 2'.` � PM Owner's Name _A Address ` f Phone Contractor's Name � License No. Phone �^ � TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK V SEWER LINES _40,1 DISPOSAL FLD. et- PROP. LINE FOUNDATION = AGRICULTURE WELL--e—F OTHER WELL PITS/SUMPS 4 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 x Type of Casing Specifications t 'I ❑ Public ❑ Other ❑ Delta " Depth of Grout Seal Type of Grout, l r Surface Seal Installed b ❑ Irrigation ---Approx. Depth EJ Y C Repair Work Done ❑ Type of Pump F H.P. State Work Done II Well Destruction' X Well Diameter Sealing Material (top 50') '�' 11. N Depth � Filler Material (Below 501 3A w TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is r available within 200 feet.) i Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms , Character of soil to a depth of 3 feet:.I Water table depth SEPTIC TANK ❑ Type/Mf I Capacity No. Compartments F PKG. TREATMENT PLT. ❑ :' Method of Disposal I Distance to nearest: Well Foundation Property Line I - LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well ' -Foundation Property Line I SEEPAGE PITS ❑ Depth ( Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 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 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 applic m for all required inspections. Complete drawing on reverse side. Signed Title: 0-1� A r-= Date: FOR DEPARyl"T"S ONLY Application Accepted by l/` ` Date Pit or Grout Inspection by Date Final Inspection by "t— Area Date i Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca .828-7104 ❑ Tracy 8355-6385 Applicant- Return all copies to: Enviroriiimental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. INFO q +EH 13-241REV.14/831-�•3 I EH 14-28