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APPLICATION FOR PERMIT M SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 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 Address r Owner's Name/1111 Address 'Sa LJ' ' Phone E-2 / d - r0 Contracts 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 i INTENDED USE _,TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS El Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I 1-1 Public ❑ Other El Delta Depth of Grout Seal Type of Grout I I Irrigation _..Approx. :Depth I I Eastern Surface Seal Installed by Repair Work Done El Type of Pump H.P. State Work Done Well Destruction '❑ -Well-Diameter""" "F y5e`aling Material (top 501 I Depther Material IBelow 50') TYPE OF SEPTIC WORK: NEW INSTALL'A'TION.1.1 .REPAI. DOITI DESTRUCTION I I (No septic system permitted if public sewer is i available within 200 feet.) Installation will serve: Residence Commercial f the ' 1 � Number of living units: u•Number of bedrooms Character of soil to a`depth oof 3 feet:, f Water table depth SEPTIC TANK ICY Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ ( Method of Disposal Distance to nearest: Welft Foundation Property Line LEACHING LINE No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation `/2" Property Line SEEPAGE PITS { I Depth Size Number SUMPS L) Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 District. ' Home owner dr 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 1 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 m s all for all requir ns ions. Complete drawing on rp4erse side. 17 Signed X Title: Date: ' FOR DEPARTMENT USE ONLY Application Accepted by Date /.2 � v� Area_G Pit or Grout Inspection by Date Final Inspection by Date 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 INFO AMOUNT RUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO_ ♦ EH13.241REV.r EH 14-26