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a l w' APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON 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-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. Job Address City Lot Size PM 1/17 Owner's Name _A eT- Address ti,�, Phone Contractor's Name " -License No. Ph l� one , 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 WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial Q Open Bottom, ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications t ❑ Public ❑ Other ❑ Delta Depth of Grout SealW ❑ Irrigation .�A Type of Grout pprox. Depth Q Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction `❑ Well Diameter Sealing Material (top 50') I lr Depth Filler Material (Below 50') I TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is T ,� t available within 2_00_ feet.J_-". _ Installation will serve: "Residence�- Commercial_ Othei - Number of living units: Number of bedrooms _ Character of soil to a depth of 3 feet: Water table depth ` SEPTIC TANK ❑ -TypelMfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line ' LEACHING LINE `•C] No. 8i Length of lines 7 Total length/siz �' F� FILTER BED Distance to nearest: Well ��j� L/� �� e yrs Foundation� property Lute SEEPAGE PITS ❑ Depth '` Size Number f SUMPS Q Distance to nearest: Well Foundation Property-Line DISPOSAL PONDS ❑ - ;-ti., hereby certify that I have prepared this application and that the work wilLbe done'in'accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San,Jaaquin Local Health District. A 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 forwhich this permit is issued-,I shall employ persons subject to workman's compensa- tion laws of California." ,Y The applicant must call for all r wired in actions. Complete drawing on reverse side., i Signed Title: " Date: FOR DEPARTMENT USE ONLY +Appiication Accepted by f tr'V�--� �Z�-g�T� . � -- ---- -Date � Area Pit or Grout Inspection by Date Final Inspection-by G'Y J Date Additional Comments, ❑ Stk 466-6781 Q Lodi 369-3621 ❑ Manteca 823-7104 Q Tracy 835.6385 Applicant- Return allcopiesto: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 f FEE AMOUNT DUE AMOUNT REMITTED s!. INFO CASH RECEIVED BY DATE PERMIT N0. + EH 13.241REV.101831 �� 40 - - r - - •� t. { . EH T426 ��rC r.---- .....