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APPLICATION FOR PERMIT SAN JOAQUIN LOHEALTH DISTRICT 1601 E. HAZE T ON 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 District. 6� �p 10 Job Address �. City Lot Size �M Owner's Name Uress w�v / Phone C Contractor0Address (cense No. �_vPhone TYPE OF WELL/PUMP: NEW ELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public F Other 1-1 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 Stop 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION t4 REPAIR/ADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence-/ Commercial_r Other' Number of living units: —/— Number of bedrooms_ n Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Ll d Method of Dis oEal Distance to nearest; Well Foundation _.__ Property Line d � LEACHING LINE ❑ No. & Length of lines Total length/size _ FILTER BED El Distance to nearest: Well Foundation Property Line - SEEPAGE BITS [ 1' Dep Number t r C t SUMPS ❑ 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 $an 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 c or all require ns ctions. Com ! e:drawing arse side. Signed X Titl -- Date: FOR DEPARTMENT USE ONLY / Application Accepted by � ��I,— Date � � � Area �r Pit or Grout Inspection by Date Final Inspection by__.&212 .2—&� Date Additional Comments: ❑ 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. Box 2009, Sik., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 9Y DATE PERMIT'f+7. J /� + EH 1&241REV.1iNal /�, V f J ( C _? EH 14.26