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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 l (Complete in Triplicate) Y Application is heieby 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 far well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address City U Lot Size / Owner's Nama �1��A&-1) /Address �i � C"�/"�1� •�-- Phone 3 Contractor Address License No. Phone._ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 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 ❑ Dia. of Well Excavation Dia. of Well Casing Industrial ❑ Open Bottom El Manteca i ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout - I I Irrigation —.-Approx. Depth i I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 '4 TYPE OF SEPTIC WORK: NEW INSTALLATION I') REPAIR/ADDITION 1 1 DESTRUCTION Nseptic system rted if public sewer is available within 200 feet.) w • Installation will serve: Residence_ Commercial— Other ;I,'Number of living units: Number of bedrooms - "Character of soil to a depth of 3 feet: afar table depth SEPTIC TANK -Type/Mfg r Capacity o. ompartmenis PKG. TREATMENT PLT. ❑ 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 1 1 Depth Size _ Number SUMPS Ll Distance to nearest: Well Foundation Property Line U 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 f rules and regulations of the San Joaquin Local Health Di§trict. t 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.Cal.ifornia._Contractor's hiring or sub ciintracting signature- certifies the following: "I certify ttf .ir p ermance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." Theapplica st call for all required inspections. Co plate drawing on reverse side. Signed X Title: Date: r _ FOR DEPARTMENT USE ONLY Dat '¢ A ea Application Accepted by / Pit or Grout Inspection by Date Final4rispaction by Additional Comments: ❑ Stk 466-6761 ❑ Lodi -3621 f ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all coI Health Permit/Services"I 1 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 7�p FEE AMOUNT DUE AMOUNTINFO ED-D: CK RECEIVED BY DATE PERMIT NO. ..EH13-244REV.I b) 3� UU 35, IS6L ( EH 14"2e