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APPLICATION FOR PERMIT I� SAN JOAQUIN LOCAL HEALTH DISTRICT ¢ 1601 E. HAZEL 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 3 City ot Size PM �L,n�r�Z Owner's Name Address _ Phone Contractor Aopr JPZddlr/Z- Address Z��4/ 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 FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i ❑ Industrial Y ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Wel! Casing ❑ Domestic/Private ❑ Gravel Pack ❑Tracy------„ i,-.-Type of Casing Specifications — M Public Cl Other F1 Delta Depth of Grout Seal T VQ ype of Grout S I I Irrigation --Approx. Depth t I Eastern Surface-Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well DiameterSealing Material (top 50') Depth Filler Material (Below-50J TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I ] DESTRUCTIO (No septic system permitted if public sewer is ailable within'200 feet.) Installation will serve: Residence Commercial her Number of living units: Number of bedrooms Character of soil to a depth of 3.feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal V Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size f FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I'I Depth Size Number M SUMPS ❑ 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 the Sari 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: "!certifythat in the performance of the work for which this permit is issued, I shall employ 1 tion laws of California." p p y persons subject to workman's compensa- The applicant must for all re din tions. Complete drawing on reverse side. Signed X Title: Date: ? } FOR DEPARTMENT USE ONLY Application Accepted by Date �~ . Area Pit or Grout Inspection by. Date-- _- Final.Inspection.by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 `n Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEECK INFO AMDUN7 DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH 13-241REV,tin51 II^_ Q / EH 14-26 W_�� /� 6 ZPZ