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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT y 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-67$1 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 welUpump and the Rules and Regulations of the San Joaquin Local Health District.. Job Address )' 'A /""] �5�_,5 f`+ M W V 9 City �Q� Lot Size PM Owner's Name 0 cr6E Address Phone / Contractor �._ l �i �� Address �a�t±l� . +-f�_, �DLicense No. Phone�j _ TYPE OF WELL/PUMP: NEW WELL EJ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION © SYSTEM REPAIR D OTHER LJ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION ' AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL 1PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca -- --tDia: of Well Excavation Dia. of Well Casing ❑ Domestic/Private 0 Gravel Pack ❑ Tracy IType of Casing Specifications Ul Public Ll Other_ ❑ Delta Depth of Grout Seal Type of Grout i I IrrigationApprox. Depth I 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') — r TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l TRUCTION l I (No septic system permitted if public sewer is . available within 200 feet.) ! Installation will serve: :Residence— Commercial_ Other p Number of living units: Number of bedroom . i-�._ -t ---•-�_— Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments +q PKG. TREATMENT PLT. ❑ : Method of Disposal J Distance to nearest:` Well Foundation Property Line ' LEACHING LINE ❑ No. & Length of lines r —Total length/size 'r FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS IZ;. opth Size Number _ + SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS El �* / 09 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 tate 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- ti n of Californ' The applica u t!call all r airs Hsps C lets drawing on r verse std Sig Title: �' � Date: `� — 17 _ f9 FOR R DEPARTMENT USE ONLY Application Accepted by Date r1� ' Area it r Grout Inspection by. Date Final Inspection by ate — / T r r r Additional Comments: ❑ Stk 466-6781 El Lodi 369-3621 ❑ Manteca 523-7104 Tracy 835-6355 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. a EH 13.24(REV.1/H 5) EH 14-28 ,� 1C3