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APPLICATION FOR PERMIT 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. t Job Address O City Lot Size PM r Owner's Na Address Phone �r r -76 Contrac Address / t License No.Y�z zGPhone D TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION Cl 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F1 Public Ll Other ❑ Delta Depth of Grout Seal Type of Grout Ow 1 1 Irrigation _Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done_ 0 Well Destruction ❑ Well Diameter Sealing Material (top_50'I -- Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATIO REPAIR/ADDITION,1,1 DESTRUCTION l I INo septic system permitted if public sewer is r �/ available within 200 feet.) _ Installation will serve: Residence! Commercial_ Other C� Number of living units: __/_ Number o Brooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg Capacity/—&MNo. Compartments 951, PKG. TREATMENT PLT. ❑ r Method of Disposal Distance to nearest: Well c�0 Fpundation Property Line LEACHING LINE No. & Length of lines `- Total length/size G j� FILTER BED ❑ Distance to nearest: Well< Foundation /" Property Line SEEPAGE PITS Depth Size Number SUMPS D Distance to nearest: Well 1490 Foundation 0(a - 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 Diltrict. 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 persons subject to workman's compensa- tion laws of California." The applicant t call for qui d inspections. Complete drawing on reverse d Signed X Title: Vi yl-� Date FOR DEPARTMENT USE ONLY �3 q I lic4ation Accepted by� � Date 1 G U Area. Pi or Grout Inspection byN'l 'y ti Data� Final Inspection by Data A 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 ION FEE INFO AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT'NO. rEH14-241REV.r/x51 Ch ��4b `�0--1325 EH 14-2e