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APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CAS IJ Telephone (209) 466-6781 ,'9 e G V PERMIT EXPIRES 1 YEAR FROM DATE ISSUED- 0 PU`' (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. f p� Job Address � © -City `� f e� Size PM Owner's Name Address �7 C- '�^ Phone 93-1--coS 55 P Contractor � 1 Q�'y� C'icense No . Phene� .7- Address +� TYPE OF WELL/PUMP: -NEW WELL-❑ WELL"REPLACEMENT-E] DESTRUCTION ❑ PUMP INSTALLATION ❑ 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 El Industrial ED Open Bottom El Manteca Dia of Well Excavation Dia. of Well Casing ❑ Domestic/Private ElGravel Pack ❑ Tracy Type of Casing Specifications M Public 71Other Cl Delta Depth of Grout Seal Type of GroutNo t "1 Irrigation —_..Approx. Depth ( I Eastern ,Surface Seal Installed by - \ Repair Work Done Type of Pump H.P. State Work Done ` Y Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth,2' \ Filler Material (Below 501 -- ( TYPE OF SEPTIC WORK: NEW INSTALLATION CI REPAIR/ADDITION l I DESTRUCTION I 1 INo septic system permitted if public sewer is ", : available within 200 feet.) Installation will serve: Residence— Commercial— Other r Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth t SEPTIC TANK ❑ Type/Mfg ,Capacity No. Compartments t. PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearesC Well Foundation Property Line Q LEACHING LINE ❑ No. & Length of lines Total length/size (� FILTER BED ❑ Distance to nearest: Well�� Foundation Property Line SEEPAGE PITS I ) Depth Size Number I SUMPS 0 Distance to nearest: Weil " Foundation '1'� 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 employ any person in such manner as to become subject to workman's co'm`pensation laws of Californias 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." J F f The a plicant call for ail require spectio Com to drawing on, erse'side. Signed X Title: s Date: r FO EPARfTfNENT-USE ONLY _ Application Accepted by / ' Date /j Area Pit or Grout Inspection by Date ,Fihal Inspection by Dateel—,Q Additional Comments: 13 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 AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT_NO. INFO + EH 13-24(REV.1/n5) EH 14-2a