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> APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA �O FIV.. 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 Districts, �* a Job Address ! / r/ �tfl �g�9 / �l i lx4 Cite-avLot Size_ PM Owner's NameAddress Phone r Conti actor z f v�L�� Address do!5Z fyf !67cA License No. gP?�Phones-1.0— TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 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 co ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing —_- _ O ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 71 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout 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 El Well Well Diameter Seating Material (top 501 _ it Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION DESTRUCTION 1 I (No septic system permitted if public sewer is ,/ available within 200 feet.) Installation will serve: Residence— 'Commercial -!� Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: cL~Ntasf— "`4 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. & Length of lines _ Total length/size FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth __ V !�K_t Size Number SUMPS vile Distance to nearest: Well/4V Foundation /ie� Property Line DISPOSAL PONDS ❑ I hereby 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 rogulationts of the'Sari'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, 1 shall employ persons subject to workman's compensa- tion laws of California." ;r The applicant must call for all re uired inspections. Complete drawing on reverse side. Signed X E --- Title: - — -/ / --- Date: $ a R DEPARTMENT USE ONLY t t �� / Application Accepted by ,` -- Date�,` Area 7 f f - / Pit or Grout Inspection by Date Final Inspection by Date r Additional Comments: - O Stk 466-6787 ❑ 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 AMOUNT DUE AMOUNT REMITTED CK tt I'- RECEIVED BY DATE PERMIT NO. INFO CASH EH 13-241REV.rine EH 14-26