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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA ii Telephone (209) 466-6781 'I PERMIT EXPIRES 1•YEAR FROM DATE ISSUED I jj .(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 3 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. � � � 1 z. Job Address k f City Lot S-_ _( �'�—^ PM �r _ Owner's Name Address Phone IS 9(- 33 R r / Contractor's Name �^+ License No. �Z j Phone p#Q' 33 TYPE OF WELL/PUMP: + NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ A PUMP INSTALLATION ❑ SYSTEM REPAIR El 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 11 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing + ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I� ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of!Pump H.P. State Work Done Well Destruction LJ Well Diameter Sealing Material Itop 501 �1 Depth ,I --FillerMaterial,(Below-50')- TYPE OF SEPTIC WORK: NEW I11 NSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ Mo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Res ence t/Commercial— Other Number of living units: Number of bed.rooins r Character of soil to a depthof 3 feet: Water table depth 06 �/ f SEPTIC TANK L� Type/Mf9 Gft — opacity No. Compartments �p PKG. TREATMENT PLT, ❑ 1 Method of Disposal Distance to nearest Well _ Foundation Property Line 36� , LEACHING LINE eNo. & Length of lines I r r g ,r�Total length/size 5 FILTER BED 17 Distance to nearesti Well—L—L��_ Foundation Property Line �O r II k SEEPAGE PITS eDepth 01 s Size � Number SUMPS ❑ Distalnce to nearest Well Foundation Property Line.� i 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, r rules and regulations of the San Joaquin Local Health District. 4 Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work;forwhich-this..permit_,is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of CaMornia."Contactors hiring or sub-co tfacting signature certifies the following: I certify f " -lily 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." II ; The applicant must call AralVraquired inspections. Complete drawing on reverse side.'^ T _ J Signed X Title: Date: FOR DEP TMENT U_SE 0NLV` Application Accepted by ° DateU— F AreaF -. /Pit�br Grout Inspection by Date '�inal lnspection.by Date =C Additional Comments: 9 ... �! ❑ Stk 466-6781 ❑ Lodi 399-3621 El Manteca"823 7104 El Tracy '835-6385' -- ^— --= Applicant- 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 RECEIVED BY DATE PERMIT`NO. w yy n + EH 13-24{REV.101834 d.-i 1,ylvss EH 1426 IRS h -