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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. Job Address City L of Size PM Owner's Name ,4dress 117//y/r��1 Phone Contractor �� Address License No. Phone Im TYPE OF WELL/PUM : NEW WELL © A fdfi DE ON ❑ P DISTANCE TO NEAREST: MPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE F UNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE rYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS OR'] ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casin � ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i'] Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 T e of Pump H.P. State Work Done _ a Well Destruction ❑ II Diameter Sealing Material (top 50') D(pth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: P IEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION^TNo septic system permitted if pub]c sewer is available within 200 feet.) Installation will serve: Re dente_ Commercial— Other Number of living units: Number of bedrooms Character of soil to a deptl of 3 feet: Water table depth \ ' SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments f� PKG. TREATMENT PCT. ❑ -. Method of Disposal" Distance ton Foundation Property Line- LEACHING LINE ❑ No. & Length f lines Total length/siie ,k FILTER BED ❑ Distance to.no Brest: Foundation Property Line SEEPAGE PITS l I Depth Si Number k SUMPS 0 Distance ton r s . Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have pr ipared this application and that the work will be done in accordance with San Joaquin county ordinances state laws, and rules and regulations of the r,an Joaquin Local Health District. Home owner or licensed age 's signature certifies the following: "I certify that in the performance of the work for which this permit is isued, I shalt not employ any person in such mi nner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-cont acting signature certifies the following: "I carti V that in the performance of the work for which this permit is issued;-f-shall employ persons subject to work an's compensa- tion laws of Cali The applicant must all for al requi ed i ctions. Complete drawing on reverse side. Signed Title: �1f�/� _..___. Date: 5r 140�� FOR DEPARTMENT USE ONLY Application accepted by VI DatelizArea Pit or Grout Inspection by,, Date Final Inspection by D e 'Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 D Manteca 823-7104 CI-Tracy 835-6385 Applidam - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE.. INFO AMOUNT DUE AMOUNT REMITTED CASH CK 4 RECEIVED BY DATE PERMIT NO. E N t4-2p 1{ I 1