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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH-DISTRICT fi 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 . f PERMIT EXPIRES 7 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. .-1' i Job Address /' de City Lot Size PM Owner's Name - d-_ - Address P Phone Contractors �' Lf J��/�y� Address L. I" 11( License Phone v TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ` FOUNDATION AGRICULTURE OTHER WELL /SUMPS INTENDED USE TYPE OF WELL P EA CONSTRUCTION SPECIFICATIONS l ❑ Industrial ❑ Open ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/ Private ravel Pack ❑ Tracy Type of Casing Specifications l ❑ ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrig 'on �4pprox.,Depth J❑ Eastern Surface Seal Installed by I -Repair Work Done ❑ Type of Pump ; H.P. State Work Done Well Destruction ❑ Well Diameter i Sealing Material (top 50') i Depth r ;Filler-Material (Below 501 � TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial Other Number of livinrg units: Number of bedrooms Character'of soil to a depth of 3 feet: t SS Water table depth SEPTIC TANK ❑ Type/Mfg' 1 # Capacity # No. Compartments PKG. TREATMENT PLT. ❑ a-0 Method of Disposal r j Distance to nearest: 1 Well Foundation Property Line LEACHING LINE ❑ No. & Length.of lines i Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth i Size Number I SUMPS ❑ Distance to nearest: # Well Foundation Property Line r DISPOSAL PONDS ❑ i 3 hereby certify that I have prepared this_application and that the work will.be done-in.accorclance-wiWSan 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, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of Caliifornia,"Contractor's hiring or sub-contracting signature r 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." Theapplicant m call for all required ins ctions. Complete drawing on rave sidle � ^� Signed Title: G �,. Date: 7 FOR DEPARTMENT-U8E,0NLY �.1 d Application Accepted by Date � Area 0 /�" Pit or Grout Inspection by Date Final Inspection Date(} i Additional Comments: ✓ ❑ Stk 466-Ml ❑ Lodi 369-3511 ❑ 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' INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIV NO. # + EN 13-24+REV.1/8 57 EH 14-26