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APPLICATION FOR PERMIT } SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA n Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED g (Complete in Triplicate) <Y 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: " J" Job Address City Lot Size PM Owner's Name E + " Address Phone Y License No, Phone S Contractor G ddress TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ F DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS f INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i ❑ Industrial ' ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I ( C1 Public ❑ Other ❑ Delta Depth of-Grout Seal Type Grout ---Approx.❑ Irrigation �4pprox. Depth ❑ Eastern Surface Seal Installed by a Repair Work Done ❑ Type of Pump H.P. State Work Done V Well Destruction ❑ `Well Diameter Sealing Material {top 501 Depth Filler Material IBelow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION L-Okmeptic system permitted if public sewer is "available within 200 feet.} Installation will serve: Re -dencelL Commercial_�Qther Number of living units:i Number of bedrooms ry I-Character,of soil to a depth of 3 feet: PrIm Water table depth JSEPTIC TANK i� i �_0, Type/'Mfg Capacity_. No. Compartments x a Method of Disposal PKG-TREATMENT PLT. ❑1- 1 „z +, f i i-DistanL to-nearest "`-"We11 " Foundation Property Line `L- F LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED { ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS? ❑ Depths Size Number SUMPS I ❑ Distance-to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ y 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 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, 1 shall not e loy any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certi the following: ertify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- . tion laws Califomi ll —""-"'' T applicant s all for i requ d ins ction ompl to drawing on rev se side. Signed r Title- i --- --- _ Date: F RTMENT USE ONLY ?? Application Accepted by ? Date 7� Area Pit or Grout Inspection by Date Final Inspection by elta 17 Date Additional Comments: t" 114 �d ❑ Stk 466-6781 Lodi 362i ❑ M" teca S23-7104 ❑ Tracy 835 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA=01 FEE AMOUNT DUE AMOUNT REMITTED) CH RECEIVED BY DATE PERMIT''NO. INFO + EH 13-24(REV.1/e 5) 3�51 �� 3. ' Ek 14.28