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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT . ON ,- 1601 E. HAZELTAVE., STOCKTON, CA Telephone (209) 466.67$1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED'' •y (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 Ryles and Regulations of the San Joaquin Local Health District. . Job Address " City Lot Size a PM -Owner's Name - Address Phone Contractor � J1!?z+ z�¢l Address - License No.��Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIRieOTHER ❑ 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 ❑ Industrial ❑ Open,Bbttom ❑.Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Graval,Pac(i �'` El Tracy Type of Casing Specifications 11Public la Other-- _ rl*Delta Depth of Grout Seal Type of Grout ❑ irrigation 'Approx. Depth.,,,,_❑ EasteOn Surface Seal Installed by Repair Work Done ❑ Type of Purr -AH.P. State Work Done Well Destruction ❑ Well Diameter' Seating-Material•{ Qp 50') 1' Depth I Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑DESTRUCTION El (No septic system permitted if public sewer is 4 available within 200 feet.l y Installation will serve: Residence— Commercial_ Other : Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:1 1 :a i (.0 " Water table depth /, SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ " Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines r Total length%si'ze c �� aq , FILTER BED ❑ Distance to nearest: Well', ' 75- Ippndation Property Line � r SEEPAGE PITS ❑ Depth # Size # Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ' _.wl'hereby certify that I have prepared this'application arid'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 ih 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 laws of California."Contractor's hiring or sub-contracting signature certifies the following: 'I certify that in the i performance of the work for which thiJ permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant ►must call fo;,alljequired inspections. Complete drawing onnrreverse side. Signed X r� G?'�e�+� Title: �l�7lL� ir�.. . Date: DEPARTMENT USE ONLY / ��- Application Accepted by ! Date Area Pit or Grout Inspection by Date Final Inspection 6y Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 Applicant-Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. r INFO mon q l �p 5--17� vS + EH 13-24(REV.t/551 EH 14-M