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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 456-6781 PERMIT EXPIRES 1`YEAR FROM DATE ISSUED UU f(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. r .� 'Z I City "'"z a� Lot Size�a0 A�JPM Job Address C 5's Owner's Name: 134C0/K Address —Z" L9 9 Phone Contract' �� ddress License Ne-:Z. " Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR El OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _"�` DISPOSAL FLO. PROLINE FOUNDATION --4�-- AGRICULTURE WELL OTHER WELL "—tits/SUMPS I _. INTENDED USE `TYPE OF WELL PROBLEM'AREA CONSTRUCTION SPECIFICATIONS ❑� Industrial pen Bottom ❑ Manteca Dia.;.pf Well Excavatio Dia. of Well Casing LSVpomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 17 Public Qn Other it Delta, Depth of Grout Seal CO Type of Grout I(f�lrrigation 7 0--Approx. Depth i I Eastern 'Surface Seal Installed by Repair'Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') ." Depth Filler Material (Below 50') — TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION { I DESTRUCTION I I (No septic system permitted if public sewer is +r �' available within 200 feel.) Installation will serve: Residence_ Commercial_ Other } Number of living units: Number of bedrooms J Character of soil to a depth of 3 --Water table depth r SEPTIC TANK ❑ Type/Mfg N.. Capacity—'_7 No. Compartments , i PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well,l"r Founda i Property Line ,.. . , r LEACHING LINE >ELID" & Len lines Total length/size FILTER BED ce to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth -/-Size Number SUMPS, Cl Distance to nearest: Well r Foundation Property Line 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 District. 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 4 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 must call for all required i pect.ons. Complete drawing on revers/side... �{ ' Signed X Title: _ N✓' _ Date: FOR DEPARTMENT USE ONLY I Application Accepted by A C2,,e Area Pit or Grout Inspection by Date Final Inspection by T - Date t Additional Comments: + °❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-71114 ❑ Tracy 835-8385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9hO (FEE AMOUNT DUE AMOUNT REMITTED CASHRECEIVED BY DATE INFO..EH13-241REV.1/1111 � P EH 14-2e