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T r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON 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 Sa4noaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San JoaquinLocal Heal District. '1�1 I! , `/' Job Address — City Lot Size PM . literII Owner's Name w dress Phone �►" Contractor Age dIn yyh5le-ticense No. J�I�Gz��Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION C7 SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS :r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS d`k ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ravel Pack ❑ Tracy Type of Casing �- Specifications r'] Public Othef {l Delta Depth of Grout Seal Type of Grout _'.I I I Irrigation I^ t {f ].Approx. Depth I I Eastern Surface Seal Installed by 77sgt� Repair Work Done ❑ Type of Pump H.P. State Work Done I I Well Destruction ❑ Well Diameter Sealing Material Itop 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEWINSTALLATIONI I REPAIR/ADDITION l I DESTRUCTION I i INo septic system permitted it public sewer is available within 200 feet.) v3 Installation will serve: Residence_ Commercial_ Other Number of living units: -ala f bedrooms I Character of soil to a depth of 3 feet: Wate IIZ SEPTIC TANK ❑ Type/Mfg Capac' No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal O Distance to nearest: Foundation Property Line f LEACHING LINE ❑ N ength of lines Total length/size FILTER BER Distance to nearest: Well Foundation Property Line " r l SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line 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 employ any person in such manner as to become subject to workman's compensation taws of California."Contractor's hiring or sub-contracting signature certifies the f g: "I certify that in t rformance of the work for which this permit is issued, I shall employ perss subject to workman's compensa tion laws Calif nia." ll The ap /cant sFcall for al �qir ' In mplete drawing on re ers side. I� Signed X ' Title: Date: IC OR DEPARTMENT USE ONLY / I Application Accepted by Date I Area Pit or Grout Inspection by Date r �p Final Inspection by Date 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 I FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO + EH 13-24 1REV.I/)15) EH 14-2e