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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 (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. Joh Address _��1, T_-_��6 � _ �O' GO�L �4ff»Ll) City 1 Lot Size PM Owner's Name r Addressp�L��I OC F�f�j �,CJS W I:>I Phone ContractorLQ�$ t•+! Address a 9*'23 Qjver - �D License No.(46f 027 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 FOUNDATIONS r AGRICULTURE WELL OTHER WELL 3aQ t PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation f Dia. of Well Casing < ❑ Domestic/Private ❑ Gravel Pack Tracy Type of Casing lfaacy "jop.F Specifications f"1 Public 9 .thee– E ❑ Delta Depth of Grout Seal ice. f Type of Grout I I Irrigation r (n J �_Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') i i Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION f I REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet) Installation wi esidence— Commercial_ Other \! Number of living units: er of bedrooms Character of soil to a depth of 3 feet: Water table depth _ SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments i PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total lengt ` FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number i SUMPS ❑ Distance to nearest: Well Foundation Property Line i 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 DiMrict. 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 I 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: "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 re ire inspections. Complete drawing on reverse side. �y Signed X , _ Title: Date: FOR DEPARTMENT USE ONLY g Application Accepted by Date Area 3 Z Pit or Grout Inspection by Date 4v'Final Inspection by Dat�� 4 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, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK ��RECEIVED BY DATE PERMIT'NO. 3 +.EH 1324(REV. EH 14-26