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n n 11 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is heieby 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 r Cit Lot 5i a PM 4 Owner's Nam Address Phone 7,5 6a x ! 6d Phone "�i/ Y -70 Contrac AddressPW,ALicense No. r TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i E PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE f FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS '+ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 3 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications fl Public I7 Other Cl Delta Depth of Grout Seal Type of Gfout I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction © Weil Diameter Sealing Material (top 501 Depthr Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1REPAI ADDITION DESTRUCTION { I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial Othe Number of living units: I Number of be oms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method-of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE No. & Lenglh of lines; Total length/size FILTER BED ❑ Distance to nearest: Well--5-0 Foundation_-_Z.O__.._.: Property Line,S SEEPAGE PITS l I epth 16 Size'.- Y'�� Number ! r SUMPS istance to nearest: Well Foundation._ ( r _ Property Line DISPOSAL PONDS ❑ I hereby certify that I have,prepared this application and that the-9i: ill 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,l shall employ persons subject to workman's compensa- tion laws of California." The applicant us call for a r qu d inspections. Complete drawing on revers si s Signed Title. �t Date: ` FOR DEPARTMENT USE ONLY 'J Application Accepted by Date �.+/�/}� Area f or Grout nspection by ate Final Inspection by p /1/ic t/`4�' Date!2 J i Additiort5l Comments: ❑ Stk 466-6781 ❑ 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 CK INFO AMOUNT DUE AMOUNT REMITTED CASH_ RECEIVED BY DATE PERMIT'NO. + EH 13-24-(REV.1/x51 ! / -39 EH 14-26 V /