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APPLICATION FOR PERMIT 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 he+eby 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 C Lot Size PM Owner's Name Address � � Phone ' _, �r o� s'4 G _ 36 1.2 ' S Contract Address License No Phone f TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ 4 t,.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 ¢ ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing O Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 11 Public ❑ Other ❑ Delta " Depth of Grout Seal Type of Grout (I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by 'Repair Work Done ❑ Type of Pump H.P. State Work Done e'Weil Destruction ❑ Well Diameter Sealing Material atop 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ( I REPAIR/ADDITIO DESTRUCTION I 1 iNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence�L Commercial_ Other ( Number of living units: Number of bedrooms 1� Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg 4 Capacity_AZ�S_0 No. Compartments PKC. TREATMENT PLT. ❑ / f Method of Disposal Distance to nearest: Well Foundation Property Line r LEACHING LINE `.No. & Length of linesC"` O Total length/size FI TER B Distance to nearest: Well 5Q Foundation i Cl I- Property Line SEEPAGE PITS GI Depth Size _ Number SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 11 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 r 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."Contractors hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws of California." W The applica m st c t for all requi d7i spez_�s. Complete drawing on reverse side, Signed Title: Date: i F R =RTMENT USE ONLY:or lica�t' ( Accccepted by _ l� ,.w •� a�� Date b �!� _ Ar t Grout insPti2on by t7ate �� Final Inspection by �/I'1�'�1 Date 1I� i 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, Sik., CA 95201 4. IEEE AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. + EH 1 3-24 EH 14-26 IREV.I/R 5) ,r 0 _ - c� j