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f ' i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 'I 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 1pump and the Rules and Regulations of the San Joaquin Local Health Districtt..} r Job Address .� 4� City f �� Lot Size � PM ) r 'i Owner's Name .'1"" Address' 4 Phone l �3� 7 Contractor's Name icense No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ f SYSTEM REPAIR © OTHER ❑ 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 Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private `►, 10 Gravel Pack ❑ Tracy Type of Casing + Specifications ❑ Public "`"' ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation 1+ --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') 4 t Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION El.. REPAIR/ADDITION ❑ DESTRUCTION'❑ (No septic system permitted if public sewer is e available within 200 feet.) Installation will serve:7-Residence ,r Commercial Other I Number of living units: Number of bedrooms_ Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity - No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal I Distance to nearest: Well Foundation Property Line LEACHING LINE No. & Leingth of lines — _ Total length/size FILTER BED, �'❑ Distance+to nearest: _Well Foundation Property Line ilF SEEPAGE PITS Depth 'Size Number SUMPS ❑ Dista=6ejto nearest: Well Foundation Property Line i DISPOSAL PONDS ❑ I 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 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 Parsons subject to workman's compensa- tion laws of California." The applicant must call for all re 'ed inspections. Complete drawing on reverse side. Signed Title: Date: q,1301T FQ DEPARTMENT USE ONLY !� y j Application Accepted Date 4'3Cl g1 Area - Q Pit or Grout Inspection y Final Inspection,b Data 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 1 6 FEE INFO AMOUNT DUE AMOUNT REMITTED CK*CASH RECEIVED BY DATE PERMIT-NO. t + EH13-24(REV.10/831 � A EH 14-28 -A Ob