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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA , Telephone (209) 456-6781 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 LTJ ` �� City Lot Size PM Owner's Name Address Phone " - Cantratc�or �.,.� .......................................... Address . y M _2� �. 'Ltiecnse - - r�t� �Plione TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR Cl OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 1 DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL I OTHER WELL PITSISUMPS I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia.*6,f Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy M Type of Casing Specifications ❑ Public z Fl Other ' 1-1 Delta Depth of Grou,tF Seal Type of Grout I I Irrigation _-Approx. Depth I I Eastern Surface Seal Irl Stalled by _ Repair Work Done ❑Type,of Pump_- --H.P. �� State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 1 .. i Depth_ _. _ _ „Filler Material.(Below50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION 1-1 REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence !_� Commercial_ Other J ' Number of living units: —_t— Number of bedrooms Character of soil to a depth of 3 feet: /+ Water table depth SEPTIC TANK ' ❑ Type/Mfg Capacity No. Compartments r PKG .TREATMENT PLT. ❑ 3r Method of Disposal Distance to nearest: ; Well Foundation Property Line LEACHING LINE No. & Length of lines e= =Total lehgth/size FILTER BED # Distance to nearest: Well Foundation ��^Property Line SEEPAGE PITS 11 Depth D —Size 1 X'l d )r(0 Number A �� s1 SUMPS — � Distance to nearest: "Well `Foundation Property Linel� � DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with Sa Joaquin,county ordinances, state iaws,�ana rules and regulations of the San Joaquin Local HeaO-District. i Home owner or licensed agent's signature certifies thl following: "I certify that in the performance of the work for 04hich 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!tiring 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 must callfor I inspections. Complete drawing on reverse side. Signed X — Title: Date:�G�r� R DEPARTMENT USE ONLY t � Application Accepted by Date -CJ Area Pit or Grout Inspection by Date Final Inspection by `� to ! `� Additional Comments: ❑ Stk 466-6787 ❑ Lodi 369-3621 El 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 f I FEE CK 4 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMtT'NO. ' +-EHt3-24{pEV-iiHS) -7000 CA, EH 1426