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APPLICATION,FOR PERMIT SAN JOAQUIN�LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA WN�r Telephone (209) 466-6781 PERMIT EXPIRES`1 YEAR FROM DATE ISSUEDlbe: •�� 1 % ,.r .. .�,. .< (Complete in Triplicate) n 0UD ,e RC1 1 TS ' 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 4 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. tl' ' - : Job Address �l�X __ s _ City Lot Size °' mita PIVh Wt?4Owner's Name Address Phone _ Contractor Address v License No - x Phonel 14 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 9 PUMP INSTALLATION ❑ SYSTEM-REPAIR ❑ 4 OTHER 1:1 DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES sr� � t, s.DISPO PROP. LINE„ FOUNDATION; AGRICULTURE WELL THER WELL ry PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA— TR•UCTIQN SPECIFICATIONS ❑ Industrial }(� Open Bottom ❑ Ma Dia. of Well Excavation Dia. of Well,Casing ❑ Domestic/Private ❑ Gravel Pack Tracy Type of Casing Specifications Y F ❑ Public 0 Other � ❑ Delta Depth of Grout Seal Type of Grout-- ❑ Irrigation pprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done Type of Pump # H.P. State Work Done Well Destr n ❑ Well Diameter Sealing Material (top 501 1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) !° 1 T Installation will serve: Residence— Commercial_ Other r; Number of living units: Number'of bedrooms ! 1 Character of soil to a depth of 3 feet: 3 Water table depth II SEPTIC TANK ❑ Type/Mfg i Capacity No. Compartments PKG.,TREATMENT PLT. ❑ Method of Disposal r Distance to nearest: Well Foundation Property line 11 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGEPITS ❑' Depth Size Number l SUMPS l ❑ Distance to nearest: i Well Foundation 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 compensation-.laws.of-California:-.Cofitractor.s•hiring•or•sub=contracting-signatate `I I 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." I '1 !cant must call if or all re U.ed ins 'ons. Complete drawing on reverse side. Signed X ( r - Title ..Date: FOR PWT- IVIENT USE ONLY t ` Date [ I Area L� i Application Accepted by Y ,,.� _-._ .- a.. Date S "d Pit or Grout Inspection by Date Final Inspection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835.6385 r.9 Applicant- Return all copies to: Environmental Health Permit/Services.1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r FEE AMOUNT.DUE, '' AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO INFO // t� - j + EH 1 -241REV.t/R5) - ©d ` ,. EH 14-28 _