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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) Application is.fieteby 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! s-3 Cit Lot Si a PM Owner's Nam Address Phone �.7 Contrac Address License No. - 4 6 Phone U "520+ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ( „ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINEq 1 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 1=1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i`I Public Cl Other CI Delta Depth of Grout Seal Type of Grout _. I I Irrigation _Approx. 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 r Material (Below 50.1 TYPE OF SEPTIC WORK: NFW INSTAL TION I 1 REPAI ADDITION DESTRUCTION I 1 INo septic system permitted if public sewer is (✓/ available within 200 feet.) Installation will serve: Residence_ Commercial_, Othe Number of living units: Number of be oms t Character of soil to a depth of 3 feel: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line r. r r E LEACHING LINE `No. & Length of lines Total length/sizego K FILTER BED ❑ Distance to nearest: Well ..Foundation Property Line 1:5 SEEPAGE PITS II I epth Number / SUMPS Distance to nearest WelIF-IQ" 'Foundation I®I Property Line -- ' DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the workiivill be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of-the San Joaquin Local Health District. f 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 applicantus call for a r qu' d inspections. Complete drawing on revers si , Signed X Title: . Date: FOR DEPARTMENT USE ONLY 'J Application Accepted by Date Z or Grout nspection by ate7 Final Inspection by i i Date Additiorlal Comments: C7 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT'NO. + EH 1321(REV.t/n5) / / ✓ _�� EH 11-2e C./