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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE i ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 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 'i 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 J a7S t� ` City tot Size PM Owner's Name f Address p:! �S / // ` ` _ Phone ir Z Z 4 Phone b' ��d Contract Address � License Ka. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ f 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 C) Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications " 1-1 Public f-} Other C1 Delta Depth of Grout Seal Type of Grout i I Irrigation _.-Approx..Depth l I Eastern Surface Seal installed by - Repair Work Done ❑ Type of Pump H.P- State Work Done 4 Well Destruction ❑ Well Diameter Sealing Material (top 501 II Depth r Material (Below ) TYPE OF SEPTIC WORK: NEW INSTALL TION Ll RE AIR/ DDITION DESTRUCTION I I INo septic system permitted if public sewer is f r-r available within 200 feet.) l Installation will serve: Residence' Commercial,/Other r Number of living units: —t— Number edroo s ✓ h c Character of soil to a depth of 3 feet l rf'►^- Water table depth V SEPTIC TANK El ,Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ �� Method of Disposal Distance to:nearest: Well Foundation Property Line LEACHING LINE-: ❑ No. & Length of lines F. F .. Total length/size x FILTER BED 4> EJ Distance Itn nearest: Well`. Foundation Property-Line,-4, SEEPAGE PITS Depth __.SLS Size fi-- Number f SUMPS -L] Distance Jo nearest:_ Well /:DO foundation�_.�.__ Property Line DISPOSAL PONDS ❑ LO I hereby certify-that I have.prepared'this application and that the work will be°d0,-in accordance.With San Joaquin county ordinances, state laws, and rules and reguiauons of the San Joaquin Local Health-Di%trict-..a----� 1 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." F The applicant m s a I for al r ed inspections. Complete drawing on reverse k f Signed X Title: 1- Date: U FOR DEPARTMENT USE ONLY licat n Accepted by rn Date Area r? 71 Pit spection by Date -�70 Final Inspection by CDJ' ti Date - fdditianal Comments: 0 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health PermiVServices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 4 FEE I i INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE P ERMIT -NO. ♦.EH13-24(REV.1/n5) itq �D £H t4-26 I