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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 t-3 PERMIT EXPIRES 1"YEAR FROM DATE ISSUED (Complete in Triplicate) Application is he+eby 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. �] Job Address I ` . City��,%" Lot Size 'S ` PM Owner's Name �Y'�`ti'�� S�t'1fl� Address Phone��3�z�19 Contractor Address License No. Phone,_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Gasing - Specifications f'1 Public Cl Other n Delta Depth of Grout Seal Type of Grout—.-- I rout .I I Irrigation r- _.Approx. Depth i l I Eastetn Surface Seal Installed by 4 Repair Work Done ❑ Type of Pump H,P. State.Work Done _ Well Destruction ❑ Well Diameter 46 Sealing Material Itop 50'1 Depth Filler Material (Below 50') J TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAtRlADDITION l I DESTRUCTION I I INo septic system permitted if public sewer is r available within 200 feet.) z Installation will serve. Residence_ Commercial Othery �'��` LA Number of living units: t Number of bedrooms 1 Character of soil to a depth of 3 feet: Sa`ti Water table depth SEPTIC TANK ❑ Type/Mfg Capacit ao ( No,Compartments `lam PKG. TREATJOENT PLT. ❑ / r Method of Disposal Distance to nearest: Wel! Foundation Property Line J �� r LEACHING LINE ❑ No. & Length of tines . Total length/size FILTER BED' _,._- ❑ Distance to nearest: _Well Foundation � Property Line SEEPAGE PITS I 1 Depth Size _ Number SUMPS ❑ Distance to nearest: 'Well Foundation Property'Cine's 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 rules and regulations of the San Joaquin Local Health D&rict.' , 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." The applicant_uuWaN for all required in s. Compl td drawing on reverse side. Signed X r'J Title: (1 k I. Date: FOR DEPARTMENT USE ONLY f Application Accepted by Date ` Z _ Area q Pit or Grout Inspection Date Final Inspection by Date 6 Additional Comment . ` ❑ 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 RECEIVED BY DATE PERMIT'NO. INFO +.EH 13.24 IAEV-r/H 51 1:H 14-2e �g ~•�