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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) y Application,is hereby made.to the San Joaquin Local Health District for a permit to construct and/or install the work Dein described. This application is made in corripliance 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. [�� If Job Address 440 7 City Lot Size PM Owner's Name Address / In Phone �l$ Contractor's Name License No. 4 57 ! Phone ( TYPE OF WELL/PUMP: NEW WELL Q WELL REPLACEMENT ❑ DESTRUCTION 171 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ F DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE z FOUNDATION ti9GRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS + ❑ Industrial ❑ Open Bottom ❑ Manteca; s Dia:'of Well Excavation Dia. of Well Casing ❑ Domestic/Private Q Gravel Pack © Tracy Type:of Casing Specifications C ❑ Public ❑ Others❑jDelta M, �Depth.of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth:' rE,Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump ' H.Pt State Work Done y Well Destruction 13Well Diameter _ Sealing Material (fir 50') 1 Depth Filler.Material (Belo ') TYPE OF SEPTIC WORK: NEW INSTALLATION Q REPAIR/ADDITION; ;DESTRUCTION 12iNo septic system permitted if public sewer is ± , available within 200 feet.) 1 Installation will serve: Residence_ Commercial_,.Other Number of living units: jdumber of bedrooms Character of soil to a depth of 3feet: r ""'� �F r Water table depth ^�. SEPTIC TANK ❑ Type/Mfg j Capacity No. Compartments PKG. TREATMENT PLT, ❑ 1 1 Method of Disposal Distance to nearest: Well i Foundation Property Line � 1 LEACHING LINE j No. & Length of lines I Total length/size FILTER BED Distance to nearest: Well Foundartion Property Line cgs t s..; -mss � — E SEEPAGE PITS ❑ 'Depth �2Q Size Number SUMPS ) y Distance to nearest: Well &5d Foundation T) ,io— Property Line 60-7,— . 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"peimit is issued,I shall employ persons subject to workman's compensa- tion laws of California." . "\ ? ,-- The applicant must call for all required inspections. Complete drawing on reverse side'. r Signed X Title: � � Date: FOR DEPARTMENT USE ONLY �f Application Accepted by DatedIy rI��4 Area Pit or Grout Inspection by Date Final Inspection by - .°v Date 7J�� 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.O. Box 2009, Stk., CA 95201 FEEAMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE. PERMIT"NO. INFO 1 + EH 3.24 426(REV.10!ffi) EH 1 l `� �,� ��