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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE-, STOCKTON, CA f f�� „�c� ' 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. Job Address .3 City Lot Size PM Owner's NamerA ` f h�� dress 5 Phone S� Contractor Address License No, Phone_ PE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TAN SEWER LINES DISPOSAL PROP. LINE FOUNDATION ' RICULTURE WELL HER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM ARE �Da. UCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ ca Excavation Dia. of Well Casing D Domestic/Private s ° ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public 11 Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation 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 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIRIADDITION I I DESTRUCTION No septic system permitted if public sewer is ailable within 200 feet.) Installation will serve: Residence____ Commercial------ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑1 No. & Length of lines Total length/size FILTER BED -' a ❑ Distance to nearest: Well Foundation Property Line 4 ' SEEPAGE PIT'S—4- 1 .1 Depth Size Number 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. 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." The applicant must call for all re fired inspections. Complete drawing on reverse side, Signed X Z,2 _, t7 � Title: Date: shs oU ,fQR DEPARTMENT USE ONLY / l� Application Accepted by -�'.(�1L�[t_ Date ( �fl x? Area If Pit or Grout Inspection by Date Final Inspection by Date (�U Additional Comments: ❑ Stk 466-6781 L1 Lodi 369-3621 ❑ Manteca a23-7104 d Tracy 635-6385 - Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DQUEE� AMOUNT REMITTED CK 00 CASH RECEIVED BY DATE (} PERMIT'NO. ♦.EH13-24MEV.1/851 EH t4-26 3