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APPLICATION FOR PERMIT j 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 r Lot Size PM Owner's Name Address Phone / Contractor Address J lJ fes/ k7d License No. 49 Phone TYPE OF WELL/PUMP;I NEW WELL ❑ ELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION C21 SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEARES 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 Bottom ❑ Manteca Dia. of Well Excavation Dia. of VJB.Casing omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications r I` Public ❑ Other ❑ Delta Depth of Grout Seal Type o1 Grout _ _ I Irrigation —_Approx. Da�th` �I 1 Eastern Surfice Seal Installed by _ Repair Work Done.,0 Type of Pump cam. '1 H.P. State Work Donel>01 ".rJ S ' li,�J Well Destruction CD Well Diameter Sealing Materia! )top 50') I Depth Filler Material (Below 501 ,"` TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION I t DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) l r, Installation will serve: Residence— Commercial Other Number of living-,nits: Number of bedrooms ^ Character of soil tela epth of 3 feet: ----Water table depth SEPTIC TANK ❑ Type/Mfg Capacity \ ,u k Wripartments I PKG. TREATMENT PLT. ❑ ,.�+ Me od of Disposal 4/ Distance to nearest: Well Foundation PrOeyne LEACHING LINE ❑ No. & Length of lines Total length/size i FILTER BED ❑ Distance to nearest: Well Foundation <'- Property Line SEEPAGE PITS l I Depth Size Number SUMPS Cl Distance to nearest: Well Foundation Property Line 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 rules and regulations of t ia San Joaquin Local Health Di�tfict. Home owner or licensed i igent'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 suc i manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the ollowing: "I certify that in the performance of the work f ch this permit is issued, I shall employ persons subje to workman's compensa- tion laws of iifornia." The applica t ust r aired inspections. Completed mg o arse side. Signed - Date-, FOR PAR ME T USE ONLY Application cc pled by Date v ~" i Area i Pit or Grout mpection b I Date Final Inspection by Date Additional Comments: �\ ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy &5-6585 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton,e., P.O. Box 2009, Stk., CA 95201 I FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMI-r NO. INFO CASH (� �y t.EH 13-24(REV.IIK5) 3 S C7c� C1 (f EH 14-26 1 O