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wu: APPLICATION FOR PERMIT SAN JOAQUIIN 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 d �� Owner's Name Address Dj�Q ��"O C Phone Contractor r �Q , IF� _ Address icense Na. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION -� ., 2 s i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ HER ❑ DISTANCE TO NEARES S TANK Z� SEWER LINES DISPO LD. PROP. UNE FOUNDA AGRICULTURE WELL ER WELL PITS/SUMPS INTENDED USE TYPE OF WELL AREA CONST ION SPECIFICATIONS D Industrial D Open Bottom ❑ Manteca of Well Excavation Dia. of Well Casing D Domestic/Private ❑ Gravel Pack ❑ Tracy Type o ing Specifications I'1 Public f_I Other . 71 a Depth of Grout Type of Grout I I Irrigation --Approx. l I Eastern Surface Seal Installed by Repair Work done ❑ Type mp H.P. State Work pone Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I 1 DESTRUCTION)< INo septic system permitted if public sewer is � available within 200 feet.) r Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms I Character of sail to a depth of 3 feet: ' Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ' PKG. TREATMENT PLT. ❑ IMethod of Disposal Distance to nearest: — Well- r- - -Foundation Property Line I LEACHING LINE ❑ No. & Length of lines € Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth I P Size Number SUMPS CI Distance to nearest: Well Foundation Property Line E 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 Diltrict. 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, employ an P tin I shat!not p y y 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 required inspections. Complete drawing on reverse side. ,Signed X 7Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by =60a�l Date Area Pit or Grout Inspection by Data Final Inspection by Data Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3771 ❑ 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 f INFO CASH f EIVED BY DATE PERMIT'NO. a EH 13241REV.t/Hsl 35 09 � EH 14-26 �"- / /