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APPLICATIQN FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT f 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 k � _P ego, PERMIT EXPIRES TYEAR FROM DATE ISSUED 1" (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. City Lot Size PM Job Addres Owner's Name d Address Phone 'k I?- ��'� Contractor OA Address04, Z, License NoPhone 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 LlOpen Bottom C3Manteca Dia. of Well Excavation Dia. of Well Casing i ik Domestic/Private C Gravel Pack ❑ Tracy Type of Casing Specifications M Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout i I Irrigation �Approx. Depth 1.1 Eastern s`NSu ce Seal Installed by - Repair Work Done .$2 Type of PumP : __ H.P. l State Work Done Well Destruction ❑ Well Diameter-1— iameter Sealing'Material Itop 501 Depth Filler Material I Below 50') — TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION I 1 DESTRUCTION I I iNo septic system permitted if public sewer is I available within 200 feet.) installation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: ; Water table depth J SEPTIC TANK ❑ Type/Mfg. Capacity No. Compartments t PKG. TREATMENT PIT. El ( Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED' w ❑ Distance ton arest:' Well Foundation Property Line SEEPAGE PITS I I Depth I Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 regulatioris of the San Joagitin-Local Health.Di§trict. 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 perinit,is issued,•1 shall employ persons subject to workman's compensa tion laws of California." ^ ' "r" —' The appli m sl call for all require pection '' OMP drawing o averse side. Signed X � b - `Title: a Date: FOR DEPARTMENT,,USE ONLY ` 2— Application Accepted by Date Area / Pit or Grout Inspection by Date Final Inspection b Date c�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 CASH RECEIVED BY DATE PERMIT NO. INFO � "EH 13-241REV.1/K5l EH 14.26 ti k