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I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL't ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1`YEAR FROM DATE ISSUED j (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. �Q � / , City Lot Size PM Job Address 01% Owner's Name _ Address Phone� � Jet) J � Phone' Contractor F- a Address icense No. TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT LI DESTRUCTION LI PUMP INSTALLATION ❑ SYSTEM REPAIR 17OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER I-INES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial L3 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing EIDomestic/Private El Gravel-Pack" ' ❑ Tracy Type of Casing Specifications Fl Public ❑ Other 7 Delta Depth of Grout Seal Type of Grout - I 1 Irrigation _Approx. Depth l I Eastern Surface Seal Installed by I Type of Pump, H. State Work Done Work Done ❑ _ p. Repair Wo T p Y .,-- ,., „ Well Destruction ❑ Well Diameter.; -Sealingi:Material (top 501 y Depth.-; - Filler Materia Below 50') REPAI ADDITION 1 ,DESTRUCTION i I (No septic system permitted if public sewer is TYPE OF SEPTIC WORK: NEW 1NSTALLATION`I ll: • ,.+;:r =K ��i available within 200 feet.) Installation will serve: Residence - Commercial's" Other Number of living units: Number of bedrooms 4 1 x t Character of soil to a depth of 3 feet: t Water table depth s Capacity r No. Compartments SEPTIC TANK ❑ Type/Mfg - p y , PKG- TREATMENT PLT. ❑ r-fi Method of Disposal. Distance to nearest: Well Foundation Property Line Total length/size LEACHING LINE No. & Length of lines FILTER BED L1 Distance to �eii_ ,nearest-'� Poundatioril 6* Property Line ,T- 3 SEEPAGE PITS 1.1 Depth Size Number i SUMPS Ll 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 San Joaquin Local Health District. c 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 followin : "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- 1 tion laws of Califor i ' t ^'. f The applican u call fo re u d inspecti omplate drawing on reverse side. �-- ' Signed X '� T'tle: r Date: i DEPARTMENT USE ONLY x a Date i�` Area Application Accepted by f_ L Pit or Grout Inspection by. ate Final Inspection by _ Date! L . t , 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, 5tk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO r 1 w.2S 046- Ell /3 l a 13-241RfV.1in51 EH 14-26