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t APPLICATION FOR PERMIT t SAN JOAQUIN LOCAL HEALTH DISTRICT !. 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED I (Complete in Triplicate) r . 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 .. t ` : Job Address � 'City Lot Size PM Owner's Name i'rt�� r � �� -z Address }. Phone ' Contractor " Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELLff WELL REPLACEMENT ❑ DESTRUCTION LJ` PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TAMC SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATON 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 r ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Fl Public Ll Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation yam+' Approx. Depth I 1 Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well"Destruction ❑ Well Diameter Sealing Matdrial-hop 50'1 t -., Depth) f=iller Material (Below 501 I E TYPE OF SEPTIC WORK: ',NEW INSTALLATION I') REPAIR/ADDITION> DESTRUCTION I 1 (No,septic system permitted if public sewer is I I i � i�s�F.� available within 200 feet.) Installation will serve: Residence_ Commercial Other Q, Number of living units: Number of-bedrooms f 3 Character of sail"to a-depth of-3 feet: ---w' --- Water table depth SEPflGzTANK ❑ Type/Mfg Capacity No. Compartments PKG.,TREATMENT PLT. ❑ r Method of Disposal Distance to nearestWell Foundation Property:Line \\\�� ' LEACHING LINE No. & Length of'lines r Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 'I I Depth Size s # Number s SUMPS L-I Distance' to nearest: 1Nell`�`-_ <"� "Foundation 1 1 �t'Property Line 4 DISPOSAL PONDS I hereby certify that I tiave 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 Joaquin1ocal Health District. 4n&- —•- «--T 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 m st call for all requiredrinspections. Complete drawing on reverse side. r� Signed X �t s �".. Title, to-k?vr Date: ^. OR DEPARTMENT,USE ONLY Application Accepted by { Date — Area Pit or Grout Inspection by �.:_a � '+�.`�" Date � Final Inspection by Date J Additional Comments: " ❑ Stk 466-6781 ❑ Lodi 359-3621 ❑ Manteca 823-7104 ❑ Tracy,P'835-6385 �Applicant - Return all copies to: Environmental Health'Permit/Services 1601 E. Hazelton Ave.; P.O. Box 2009, Stk., CA 95291 FEE l INFO AMOUNT DUEJ 'AMOUNT REMITTED CK RECEIVED BYDATE w PERMIT'NO. +.EH 13-241REV. t/iii 53 �'C) ?(] 0 {5� ��--09 —9, EH 1428 1111 L r �]