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APPLICATION'FOR PERMIT SAN JOAQUIN LOCAL HEATH DISTRICT # 1601 E. HAZETON AVE., STOCKTON, CA ' Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FRgW DATE ISSUED ( (Complete in Triplic`Ite) 1 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'"T,well/pump and the Rules and Regulations of the San Joaquin Local Health District. ,. ! P k LA [7 City Lot Size PM Job Address An Owner's Named-�---— Address (.t Phone r Contractor's Name c �� -cense No. L Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 11 DESTRUCTION ❑ i PUMP_INSTALLATION ❑ SYSTEM REPAIR>11 OTHER ❑ t 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_ r ❑ Industrial —ED Open Bottom ❑ Manteca Dia. ditWell ExdavatAorS�i Dia. of Well Casing r Domestic/Private' ❑-Gravel Pack .F ❑ Tracy I Type of Casing Specifications ❑ Public ❑ Other + ❑ Delta Depth of Grout Seal ~` ,Type of Grout ❑ Irrigation -L-LApprox. Depth LI Eastern Surface Seal Installed by u j Repair Work Done Type of Pump '5-cLJZ— H.P. State Work Done G= Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 54'} TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted.if public sewer.is 6 } available withi&200:feet.) L) -Y Installation will serve: Residence I Commercial_ Other 1L Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: y ` 4 "' Water table depth s i SEPTIC TANK ❑ Type/Mfg Capacity Nb'. Compartments Method of Disposal PKG. TREATMENT PLT. ❑ Distance to nearest: Well Foundation Property.Line ' l LEACHING LINE ❑ No. & Length of lines Total length/size' FILTER BED ElDistance to nearest: Well. Foundation PropertyiLine SEEPAGE PITS ❑ Depth j i Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby cert( that I have prepared this application and that the work will be done in accordance with San,Joaquin county ordinances, state laws, and certify Health District. rules and regulations of the San Joaquin Local H e 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." 1 The applica call for all required ' spectio . Complete drawing on reverse side. j I Signed Title: r Date: FOR DEPARTME USE ONLY t Application Accepted by v Date t ; �Area Z Pit or Grout Inspection by Date Final Inspection by Date c Additional Comments: VF [I Stk 466&781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835 6M f f Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 AMOUNT DUE AMOUNT REMITTED CK it RECEIVED BY DATE PERMIT NO. FEE CASH INFO C + EH13-241REV.101911 - £H 1428