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" APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i 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 for well/pump.and the Rules and Regulations of the San Joaquin Local Health District. cl J Job Address L� f " �— � - i( � �� City.-4& Lot Size PM Owner's Name Address Phone 7/�� ' Contract ress License No. Phone fy TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ( PUMP 1NSTALLATION ❑ SYSTEM REPAIR ❑ OTHER D- .- DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL^FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS;y-_ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _ ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private I ❑ Gravel Pack ❑ Tracy Type of CasingSpecifications E 1-1 Public 17-1 Other f 1 Delta Depth of Grout SealT ;kype of Grout I I Irrigation _Approx. Depth I 1 Eastern Surface Seal Installed by 1 y Repair Work Done CJ Type of Pump H.P. state Work Done _ V Well Destruction ❑ Well Diameter Sealing Material (top 501 rfi Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION (N ATION I 1 'REPAIR/ADDITION 11' DESTRUCTION 11' o septic system permitted"[public sewer is ! available within 200 feet.) Installation will serve: Residence_ Commercial_ Other ^ Number of living units: Number of bedrooms' Character of sail to a depth at 3 feet: # Water table depth SEPTIC TANK ❑ Type/Mfg 1 pacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal 1 Distance to nearest: Well Foundation Property Line l s . i r t LEACHING LINE ❑ No. & Length of lines ' T tel length/size �. FILTER BED EJDistance to nearest: Well oundation Z� Property Line [, t SEEPAGE PITS ' i I. Depth Size Number= I r o SUMPS 0 Distance to nearest:; Well Foundation _ Property Line DISPOSAL PONDS ❑ - - I hereby certify that I have prepared this application-and that the work will-be-doe''n accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local`Health Distnct.'y' Home owner or licensed agent's signature. km certifies the following:-;'Nertify 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 woran'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," 't The applicant t call for quired in coons. Comploite drawing on reverse side. r - C I Signed X �a .Title: G Date: y + 'FOR-DEPARTnAENT USE ONLY F. p Application Accepted by �^-C� 'f ` Date �a` D Area Pit or Grout Inspection by Data' +final Inspection by Date 1 Additional Comments: ❑ Stk 466-5781 ❑ 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 RECEIVED BY INFO DD�� t CASH DATE PERMIT'NO. +.EH13-241REV.rin5YO � 1� 9- ! EH 16-29 �l�