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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ,:. 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 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 Local Health Dist/ri�c+tt.. Job Address f c� Cit Lot Size PM Owner's Name Address Phone 1` L," dress �"'R' License Nom Phone Contractor s TYPE OF WELL/PUMP: NEW VALL X WELL RWACEMENT ❑ DESTRUCTION CJ "PUMP INSTALLATIOWO— SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC 4NK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDAT)QN AGRICULTURE WELL` OTHER WELL PITS/SUMPS INTENDED USE a TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS .E] Industrial 0-Open Bottom:, ❑ Manteca Dia. of Well Excavati n " Dia. of Well Casing * ❑ Domestic/Private E Gravel Pack q- ❑ Tracy Type of Casing Specifications /f t 1'1 Public 1-1 Other Ll Delta Depth of Grout Sealf! . Type of Grout i-I Irrigation _..Approx. Depth l I Eastern Surface Seal Installed by - f Repair Work Done 'D Type of Pump AUG H.P. f State Work one Sealin Material Ito 50'1 -- Well Desii:uction �:' ❑ Well Diameter � g � P Depth Filler Material jBelow 50'1 0,kn:�,_P l _ TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION 1 1' DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial Other ..Number of living units:. Number of bedrooms T Character of soil to a`depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments / ' PKG. TREATMENT PLT. ❑ E Method of Disposal Distance to nearest: Well Foundation Property Line > r BLEACHING-LINE ❑ No. & L`ength of likes "� � � � � Tota! length/size FILTER'BED �.� I] Distance to•nearest: Well Foundation Property Line SEEPAGE PITS ` 1 1 Depth Size Number SUMPS -0 L1 Distance to nearest: ' Well Foundation .Property Line DISPOSAL PONDS ❑ t 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. V r 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."-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." f Theapplicant st call for al re uire c' ns. Complete drawing on reverse side. Signed Title: Date: a OR DEPARTMENT USE ONLY Application Accepted by Date �-` `-r Area Pit or rp Inspection by Dat Inspection 7�</0 Final Inspection by� �' /c i9�$ C1�rebate ,b ti 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 F: t kFEEO AMOUNT DUE MOUNT REMITTED C 5H RECEIVED BY DATE PERMIT'NO. ,. s`+''.EH 11324 ' I �0 EH -2e lb�qj �J. 1,0 i