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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 ICompiete 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. � Job Address V S City—_ at Size PM w yOwner"s Name _ �" Address r 9 - 5-36 o Phone y6v-�q Contractor Address_ � License No. Pholr Z TYPE OF WELL/PUMP: NEW WELL C WELL REPLACEMENT ❑ DESTRUCTION ;] p PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O ; I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLD. PROP. LINE - i FOUNDATION — AGRICULTURE WELL .._ OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial r ❑ Open Bottom O Manteca Dia. of Well Excavation Dia, of Well Casing ❑ Domestic/.Private ❑ Gravel Pack 11 Tracy Type of Casing_.. .. _ Specifications t ("I Pubric n Other 1-1 Delta Depth of Grout Seal =_.__ Type of Grout d — r ---- I I Irrigation �.Approx. Depth I i Eastern Suiiace Seal Installed by E Ql Repair Work Done ❑ Type of Pump H.P-___ State Work Done Well Destrucfion J Well Diameter Sealing Material (top 501 f Depth I Filler Material i8elow 50'1 TYPE OF SEPTIC WORK: NEW INSTAI LATION IT REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted it public sewer is t j� available within 200 teet.l I � f Installation will serve: Residence— Commercial— Other_- Number of living units: Number of bedrooms - I ttt Character of soil to a depth of 3 feet: i Water table depth—, - 1 SEPTIC TANK ElType/Mfg_ '8 Capacity _Q_ No. Compartments ) PKG. TREATMENT PLT. ❑ t Method of Dis��posa�� ___ :Distance to 66rest:, Well�__- Foundation � Property Linef� LEACHING LINE ❑ 'No. & Length of lines . Total length/size_ . C FILTER BED ❑ Distance to nearest:, Well _ _ oundation Property Line r t L SEEPAGE PITS I I Depth_Size— t7. Number SUMPS Ll Distance to riearest: Well fly Foundation r I C _�_-_ Property Line DISPOSAL PONDS i t� i t 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 perrriit is issued, I shalt 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:"1=rectify 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." ► r The applicant must call for Lrequired +ections. Complete drawing on reverse side. Signed X Title: r• {Date: o EPARTMENT USE ONLY t y r� r ApplicationAccepted'by _ Date SSL,-� Area ! I _/�?" r Pit or Grout Inspection by Date f -- _. Final Inspection by Dat Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 �rtt L] Tacy 835-6385 4 Applicant . Return at[copies to: Environmental Health Permit{Services 1601 E. Hazelton Ave., P.O. Box 2009, 52k., CA 95201 _ FEE INFO AMOUNT DUE AMOUNT REMITTED CABN RECEIVED BY DATE PERMIT'NO. . EM13-24IRtV.i/nsrV EH 1f2e v