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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. 1662 for welUpump and the Rules and Regulations of the San Joaquin Local Health District./ r� Job Address / / 1&z4 - - --Lot Size PM �tt�? y 7 Owner's [� ddress Phone 93� License N*S_&__Phone��!' d`!� TYPE OF WELL/PUMP: NEW WELL ❑ WELL R PLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK_,_ SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATI6N .AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF ELL -_ PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ ndustrial ❑ Open Bottom-�-v-D.Manteca Dia. of Well Excavation Dia. of Well Casing omestic/Private 0 GravelIPack ❑ Tracy Type of Casing Specifications FI Public ❑ them fl Delta Depth of Grout Seal Type of Grout l I Irrigation rou. De th I I Eastern S rface Seal instatled-by LL C Repair Work Done C�" -Type of Pump 11 ! H.P. State Work Done r Well Destruction ID WdD ameter Sealing Material !to 50'I ^- Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION t 1 REPAIR/ADDITION I i DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will setveResidence_ Commercial_ Other Number of living units: Number of bedrooms IV Character of soil to a depth of 3 feet: Water table depth (T, SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments `l PKG. TREATMENT PLT. ❑ r Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation _ Property Line SEEPAGE PITS l I Depth Size Number SUMPS Cl Distance to nearest: Well Pofingation Property Line f 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 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 ` call f r al a wired inspections. Complete drawing on rev a si Signed Title: Date: � s GrD OR DEPARTMENT USE ONLY a Application Accepted by Date � Area Pit or Grout Inspection by Date Final Inspection by ` SV 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 AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH + EH 13-241REV.i/K51 35 EH 14.26