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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 (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. t� Job Address 1 rr;� e- "'� �R - City �Qb Lot Size PM Owner's Name Addr/esss ((x1 t ` d� �'�- Phone I Contractor,°Qy �� `�r� Address ._?_J`" p� 11 License No. Yte�? � Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT El DESTRUCTION ❑ hI PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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 y 11 Industrial LJ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 1 I 1"omesti rivate lriravel Pack ❑ Tracy Type of Casing S Vvc_ Specifications JbV'J os'l4l l"1 Public I.1 Other F1 Delta Depth of Grout Seale{-`L t-E Type of Grout I I Irrigation —..App(ox. Depth I I Eastern Surface Seal installed by _ Repair Work Done U Type of Pump c� H.P. 01fam Wr)fk'In ,ne _ �E Well Destruction Q Well Diameter Sealing Material Itop 50'1 r` " ,, ` `eo �t r Depth C/Nr(� Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION l I DESTRUCTION I 1 INo septic system permitted if public sewer is I available within 200 feet.) Installation will serve: Residence_ Commercial____ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK LJ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal f Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of tines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS CI Distance to nearest: Well Foundation Property Line f DISPOSAL PONDS ❑ 1 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 permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature certifies the following: "I certify 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." 1 The applica ust call for all required inspections. Complete drawing on reverse side. 2 Q' Signed X Title: Date: - r FOR DEPARTMENT USE ONLY Application Accepted by Date [1 7 Area—V2-2- Pit rea L2Pit or Grout Inspection by Date 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 FEE i INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT IVO, + EH 13-241REV.iinSf 11. 39� I EH 14-28 `` }