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APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON CA i Telephone (209} 466-6781`-- PERMIT EXPIRES TYEAR FROM DATE ISSUED iComplete 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.- 9Se?. d Job Address City Lot Size 10 $_ PM i Ph1i�phY�-� /� i )Owner's Name &A Address Phone Contractor Address r License No.265*,_79 f Phone TYPE OF WELL/PUMP: NEW WELL. WELL REPLACEMEN ❑ DESTRUCTION Cl PUMP INSTALLATION E SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE �¢Q_ FOUNDATION AGRICULTURE WELL �_.�_ OTHER WELL 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 g'Gravel Pack ❑ Tracy Type of Casing SII Specifications /.dp (-I Public (_1 Other 0 Delta Depth of Grout Seal mm S'd - ___ Type of Grout fl � 1 I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Y Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I.`1' REPAIR/ADDITION l I DESTRUCTION I I INo septic system permitted if public sewer is i available within 200 feet.I Installation will serve: Residence— Commercial_ Other u' Number of living units: Number of bedrooms 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 �A Y F Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size I FILTER.RED--- - •❑ =Distance to nearest: • T-Well -" Foundation Property Line -- .—....1 .r-_" i SEEPAGE PITS i I Depth Size Number 1 SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I 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, an i 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 applicant must ca far all r quired inspections. Com drawing on reverse side. Signed X TiNe: Date: i FOR DEPARTMENT USE ONLY rr Application Accepted by Date lo—3U �] Area `�t Pit or ro Inspection by Date r 'Ki Final Inspection by Date Additional 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.Q. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. t +.EH 13-24(REV.1/k5) O - O a�� EH 14-26 I ' I