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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 L r PERMIT EXPIRES TYEAR 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 t Local Health District. � / 1 �Iy � �� Job Address 1 p C-8~c{/►fEA _ CityLot rSize PM 7 Owner's Name u k"-`� Address O j r "� Phone Contractn�7� --r= 1 � AddressI > L� tLicenseNo, 3y� Phone S `� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION I SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC.TANK SEWER LINES DISPOSAL FLD. PROP. LINE r 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 V_Domestic/Private • LJ Gravel Pack ❑ Tracy Type of Casing Specifications n Public n Other -, Ll Delta Depth of Grout Seal Type of Grout i I krigation —.Approx.—Depth [ I Eastern j f Surface Sual Installed by _ Repair Work Done ❑ Type of Pump H.P, f� - State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') _ Depth Filler Material (Below 50'1 -- TYPE OF SEPTIC WORK:., ,NEW'INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet.i Installation will serve: Residence_ Commercial_____ Other O Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth I SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal ~'*'--+Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No-.41ength of lines., Total length/size FILTER BED ❑ Distance to'nearest:' W611v Foundation Property Line..--- SEEPAGE PITS i I Depth Size SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ `✓'' I hereby certify that I have prepared this application-an`d that the-work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin_Loc'a1 Health District. Home owner or licensed agent-s-signs ut re 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: "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 applican tQ11for�re�uirEdinspections. Complete drawing on averse side. Signed X --- Title: ��— Date: OR EPARTMENT USE ONLY Application Accepted by .. �/, Date Area f Pit or Grout Inspection by Date Final Inspectionb Date 71 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ 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 CK INFO CASH RECEIVED BY DATE PERMIT NO. -EH 1 124 1 REV.1/k s l EH 14-26 i