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4- APPLICATION FOR PERMIT /— SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.,HAZE 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 forwell/pump and the Rules and Regulations of tfte San Joaquin Local Health District. {, , Job Address City Lot SizaX v 00 0 PM Owner's Name Address ` e Y ! y Y Phone Contractor r ,e ress 9 ` �/ ,r License No. x391Phone TYPE OF WELL/PUMP: NEW WEI J`171WELL REPLACEMENT ❑ DESTRUC_T,ION•.❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE"TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS IN�ENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Ind'ustrialf^:.1 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing y ❑ Domestic/Private C] Gravel Pack 0 Tracy Type of Casing Specifications f I ❑ Public A ❑ Other ❑ Delta Depth,of Grout Seal Type of Grout i I ws. ❑ Irrigation Q5 ---Approx. Depth El Ea'ern Surface Seal Installed by (� Repair'Work Done#' ❑ Type of Pump r H.P. State Work Done I � i Well Destruction I❑ Well Diameter Sealing Material (top 50') � # Depth Filler Material (Below 501) y a TYPE O F SEPTIC WORK: N W�INSTALLATION ❑ REPAIR/ADDITT ❑ ESTRUCT:&avai Nc septic system permitted if public sewer is Is within 200 feet.) Installation will serve: Residence Commercial? Other p } I ` 1 Number of living units: v} Number of bedrooms , �Cha�acter of soil to a depth of 3 feet: �, Wate table depth SEPTIC TANK ❑ Type/Mfg Capacity____i No. Compartments E PKG. TREATMENT PLT. ❑ t!� ' Method of Disposal �- Distance to nearest: V1'leil Fo ndation Property Lid ne� 1 LEACHING LINE ❑ No. & Length of linesTotal length/size FILTER+, BED ❑ "Distance to nearest: Well Foundation Property Line b SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ C6tance to nearest: Well Foundation 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 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's compensa- tion laws of California." The applica must call for all squired inspections. Complete drawing on reverse side. Signed4 Title: Date: ! ' FOR DEPARTMENT USE ONLY Application Accepted bya Date_ Area Pit or Grout Inspection by Date _ Final Inspection by, Additional Comments: f�' ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8356385 Applicant- Return all copies to: Environmental Health Permit/Servioes 1601 E. Hazelton Ave., P.O. Box 2009,Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED UK RECEIVED BY DATE PEgMIT'NO. INFO CASH + EH 18-241AEV.7/s573S'r.Q� EH 1426