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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 he,eby 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. Job Address () FJ City Lot Size IF Owner's Name Address ✓�� 14 ft k2 LJ Phone 4 I //�� E Contractor _ C. tddress 5V 101- License No. Phone TYPE OF WELL/PUMP: NEW WELL El WE REPLACEMENT ❑ DESTRUCTION El _ PUMP,INSTALLATION ❑ SYSTEM REPAIR ❑ 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.— El Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specification t7 Public F1 Other ❑ Delta Depth of Grout Seal Type-of'Grout Q I I Irrigation '_Approx. Depth t i Eastern Surface Seal Installed by_ ----" Repair Work Done ❑ Type of Pump H,P. State-Work Done_ Well Pe ruction ❑ Well Diameter Sealing Material (top 50'), - Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION EPA ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is � available within 200 feet.) Installation will serve: R dence Commercial l Other Number of living units: Numbe o bedrooms L - T-- --_ T Character of soil to a depth 3 feet: --- Water table depth SEPTIC TANK iB---Yype/Mfg Capacity . /11W No. Compartments PKG, TREATMENT PLT. ❑ / Method of s Sat Distance to nearest: Well/-m Foundation ��. Property Line LEACHING LINE S�-1 oo- & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well I'll Foundation Property Line j SEEPAGE PITS i Depth �S Size ` �y Nur�l�er SUMPS t.1 Distance to nearest: WeII�_ pundation J Property Line _L_ ` 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. —•—•i 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 l employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature i c Mies 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 law alito ia. The applic nt t call fora re drawing on verse side. r �J �� Sig ills: Data: r FOR DEPARTMENT USE ONLY j Application Accepted by Date Area � ' .�..-"^�",-- - - _ it or Grout Inspection by Date Final Inspection by Date A ditional Comments: C' J Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 FEEAMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH . arl 13-24 s 28 tREv .1/9h)