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• w APPLICATION-fOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT (� 1601 E. HAZEL T ON AVE., STOCKTON, CA +I' 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. / c Jab Address �� ! �-- ,— City zzem�lt Size PM Owner's Name CA Address c�CK— Phone 4 License No. 0 0 Phone Contractor's Name TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR T!R:—' 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 V\] ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. 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 ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal-installed by S Repair Work Done Type of Pump a H.P. State Work Done v Well Destruction ❑ Well Diameter Sealing Material jtop 501 Depth Filler Material 1Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 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. ❑ y �: Method of Disposal ^- ; Distance to nearest: I Foundation Property Line LEACHING LINE ❑ No. & Len of lines Total length/size { FILTER BED ❑ Dista to nearest: Well Foundation Property Line SEEPAGE PITS yDepth Size Number *. SUMPS !El Distance;to.nearest: '` Well M„ Foundation Property Line DISPOSAL PONDS _�` ❑ .F- a- hereby certify thafrI. 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. 4 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." Cohtractor's hiring or sub-contracting signature certifies the folly I i6g:"I certify that in the performance of the work for which this permit is issued,I shall employ persons subject fo workman's eompensa tion laws of California."_ - / The app must all for all requir inspect S. Com to drawing on reverse side. Signed Title: 5 Date: FOR DEPARTMENT USE ONLY io"LzArea Application Accepted by Date � I Pit or Grout Inspection by Date Final Inspection by)6 LDate ` Additional Comments: ❑ Stk 466-6781 ❑ Lodi. 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-fivi85 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 CASH RECEIVED BY DATE PERMIT`NO. INFO / +EH 13.24(REV.10!831 r� EH 14-26