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1 APPLICATION FOR PERMIT 1 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA 1 Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ` (Complete in Triplicate) Application is hereby mads 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 Cit Lot Size PM Owner's Na Addres Phone Contract Address _ _ icense IVo ��ZSO Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEME DESTRUCTION LJ PUMP INSTALLATION ❑ SYSTE PAIR C1 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINE DISPOSAL FLD. PROP. LINE FOUNDATION AGRI URE WELL OTHER WELL PITS/SUMPS I INTENDED USE TYPE OF WELL PRO AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom Manteca Dia. of Well Excavation Dia. of Well Casing / ❑ Domestic/Private ❑ Gravel Pac ❑ Tracy Type of Casing Specifications F l Public f 1 Othe Cl Delta Depth of Grout Seal Type of Grout _ I i Irrigation ._Approx. Depth l I Eastern Surface Seal Installed by _ 1 Repair Work Done Type of Pump H,P. State Work Done l Well Desttucti ❑ Well Diameter Sealing Material Imp 54'1 yDepth Filler Material (Below 50') Q) TY E_OF. SEPTIC WORK: NEW INSTALLATION t REPAIR/ADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is I available within 200 feet.) Installation will serve: Residence_ Commercial_ Other ' + Number of living units: Number ofbe drooms I Character of soil to a depth of 3 feet: Water table depth o� SEPTIC TANK EehoType/Mfgr Capacity !�Pr-r No. Compartments I PKG. TREATMENT PLT. I-) :Method of Disposal Distance to nearest: Well Foundation erty.l_ine LEACHING LINE No. & Length of lines ��, Total length/size 17e FILTER BED' ❑ Distance to nearest: Well Foundation Property Line 4z SEEPAGE PITS lk Depth Size �� _ Number SUMPS ❑ Distance to nearest: Well Foundation Property Line k DISPOSAL PONDS ❑ at 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. _ 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."Contractor's 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." The applicant must c for all required i ctions. Complete drawing on reverse-side:. . Y 1 � Signed X Title: Date: + r FOR DEPARTMENT'USE ONLY Application Accepted"by r . Date-' O / Area 42, Pjt.or.Grout.lnspection by ---- ate Final Inspection byteVY t _!a,- �. J _s, L .Additional Comments. k ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 S Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE 41 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIl +.EH 13-24 1REV.I/n 51 EH 14-2e �/ Q