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APPLICATION FOR PERMIT } SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED _ (Complete in Triplicate) �-3 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 Ryles and Regulations of the San Joaquin Local Health District. Job Address �p City Lot Size PM n � f �4 Owner �'s Name Address H Phone Z �) p Address + O License No Phone 6 t , Contractor�Q / 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 WELI_ PITS/SUMPS ► �� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS { ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑,Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications O� 171 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout C] Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Stop 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is 1 available within 200 feet.) I I `:Installation will serve: Residence_ Commercial— Other f IINumber of living units: Number of bedr ms JJ;Character of soil to a depth of 3 feet: AwlWater table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments { PKG. TREATMENT PLT. ❑ Method of Disposal i Distance to nearest: Well Foundation Property Line 1C LEACHING LINE No & Length of lines Total length/size x Z FILTER BED ❑ Distance to nearest: 'Wed ZAD1 4' Foundation Ln 4 Property Line! j! SEEPAGE PITS Depth V Size X �s Number- k SUMPS ❑ Distance to,nearest; Well Foundation 1011— Property Line DISPOSAL PONDS ❑ I I4hereby certify that I have prepared this application 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 cert-rfies 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- r tion laws of California." The applicant mu call for all repuired ' spections. Complete drawing on reverse ide. - igned Title: Date: SS S II'll 7 -r' FOR DEPARTMENT USE ONLYf Application Accepted by Date �� Area ,� tdditional r Grout Inspection byDates- Final Inspection byG'�:-s Date Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6395 a Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. fe INFO .+ EH 13-2a MEV.1/a 5) �1<- •�� _ EH 1426 i ,