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- APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT r 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 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 G City 5_a4`""'tot Size PM Owner's Nam Address Phone Contractor' Address RY94dr ��. vv License No;�77?6Kf Phone ✓ 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' � '❑ Open Bottom O-Manteca Dia. of Well Excavation Dia. of Well Casing r V Domesticl Private t❑ Gravel Pack,r ❑ Tracy Type of-Casing Specifications- {`l Public 'IF] Other fn Delta Depth of Grout Seal Type of Grout n I I Irrigation �.-Appromx. Depth l I Eastern Su ce Seal Installed by Repair Work Done Type ofPup H.P. State Work Done C Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK:, NEW INSTALLATION l 1 REPAIR/ADDITION I I DESTRUCTION I I ;No septic system permitted if public sewer is s ;�. A-�M-�--- .. -*%1. available within 200 feet.) Installation will serve: Residence_ Commercials Other Number of living units:' Number of bedrooms Character of soil to a depth of'3 feet:. Water table depth SEPTIC TANK 11 Type'/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Method of Disposal 4 Distance to nearest: Well Foundation Properly Line r LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED df '❑ Distance to nearest: Well Foundation Property Line _ SEEPAGE PITS ✓ r ll I Depthv— Size` Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ IE hereby certify that I have prepared this applicatio-n 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." 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' compensa- tion laws of California." >` The applicant t call for all required i ctions ompl drawing on rev. so side. Signed X Title: _ �T//Jl�� S Data: FOR DEPARTMENT USE ONLY } Application Accepted by Date IZ_Cl "�Araa ` Pit or Grout Inspection by Dat Final Inspection by Date Z Additional Comments: ❑ Stk 466-6781 0 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CK 9 ASH RECEIVED BY DATE PERMITNO. +.EH 1 -241AEV.V/H5) EH 4