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'I a 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. Job Address City Lot Size PM Owner's Name Address Phone 2. + �r Contractor ddress_44 ` _ / i c e n s e No Phone ,ll TYPE OF WELL/PUMP:: NEW WELL ElWELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION-❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WFLL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom ❑ Manteca Dia.:of Well Excavation- Dia. of Well Casing ❑ DomesticlPrivate ❑ Gravel Pack ❑ Tracy Typ of Casing Specifications 1-1 Public - ❑ Other 171 Delta ✓`Depth of Grout Seal Type of Grout__ I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by y Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter -"Sealing Material Itop 50' Depth } Filler Material (Belo I TYPE OF SEPTIC WORK: NEW INSTALLATI N-I I REPAIR/ADDITION IV DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Resi nye Commercial_ Other Number of living units: umber of bedrooms i Character of soil to a depth of 3 feet: F Water table depth SEPTIC TANK ❑ ••Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ � `") _ Method of Disposal Distance to nearest: Well Foundations 1 Property Line l LEACHING LINE ❑ No. & Length of tines Total length/size E FILTER BED ❑ Distance to nearest: Well 'Foundation Property Line r SEEPAGE PITS I'I. Depth F Size Number SUMPS Ll Distance to nearest: Well Foundation b Property Line r DISPOSAL PONDS ❑ F it 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 M 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 call for all requir s ctions. Complet rawing on reverse side. Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date �• Area Pit or Grout inspection by Date Final Inspection b o 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 INFO AMOUNT DUE AMOUNT REMITTED CK A CASH RECEIVED BY DATE PERMIT'NO. +.EH t3 24 IPEV.i H 51 P1 i' �,� (/� s / � l EH 14-28 0 666 F