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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON 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/orinstall the work herein described. This application is i 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. I Job Address ZWZZ City Lot Siz //L PM Owner's Nam./,4 Address �– +��"� - Phone at r Contractor's Name License No. 3V S- 7. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION n f PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Pia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy ;,,:Type of Casing Specifications ❑ Public ❑ Other ❑ Delta ".. Depth of Grout Seal Type of Grout r ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by J Repair Work Done ❑ Type of Pump H.P. State Work Done 1 Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION LJ, REPAIR/ADDITION ESTRUCTION ❑ (No septic system permitted if public sewer is Z available within 200 feet.) Installation will serve: Residence a�Commercial Other + Number of living units: Number of edrooms/ m )�] Character of soil to a depth of 3 feet: ( © Water table depth ci'�'f �/ SEPTIC TANK ❑ `Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ – Method of Disposal . Distance to nearest: Well Foundation Property Line U( � LEACHING LINE f No. & Length of lines I r �eTotal length/size FILTER BED 11 Distance to nearest: Well_ Foundation 35 t Property Line SEEPAGE PITS ❑ Depth 10 Size 424 loxa0lNumber f SUMPS 19—Distance to nearest:, Well c Foundation -d 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. 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."Co6tractor'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 rr all f II q 'e' itspections. Complete drawing on re rse side. C.t�� f� Signed /Q- '�" Title: y Date: _ a FORD PARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by7'. Date Z ' Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104- .F t3 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 RECEIVED BY DATE PERMIT"NO.- INFO CASH +EH 13-241REV.16!831 EH 14-28 1 O