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APPLICATION FOR PERMIT r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E HAZEL TION*AVE., STOCKTON, CA 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 ci ),Size PM Owner's Name - ddress i Phone �� aL� -Contractor. L21D' Address License No: Phone 3 TYPE OF WELL/PUMP( NEW WELL ❑ WELL REPLACEMENT Ef 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 ❑ Ind ial El Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing �\ omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing -- Specifications Y. ❑ Public Cl Other. ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation pprox. DepA=; Surface Seal Installed by Repair Work Pone Type of Pump .P. �`- State Work Done Well Destruction ❑ We11 Diameter, Sealing Material (top 501 Depth +f . Filler Material (Below-50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is Y�� available within 200 feet.) Installation.will serve: Residence�"-Commercial Other f Number of living units: Number of bedrooms 4-" "." t,�„�:--=-� t_ Water table depth Chara&er'of soil to•a depth of 3 feet: SEPTIC, -' -' — 1kCapacity No. Compartments __. PKG. TREATMENT PLT. ❑X . ', - „� Method of Disposal Distance to rieearesf: Well' r. Foundation} Property Line jLEACHING LINE CINo. & Length of lines Total length/size u FILTER BED ❑ Distance to nearest: Well Foundation Property Line i SEEPAGE PITS ❑ Depth Size .. Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and i rules and regulations of the San Joaquin Local Health District, L111 I Home owner or I' nt's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not I employ any son in such riner as to become subject to wo an's compensation laws of California."Contractors hiring or sub-contracting signature certifies th 11 win - "I cc t tin the perfor ce t wo for whi this peirn t is issued,I shall employ persons subject to workman's compensa- tion la of Celiforni ." The ap icant us for require nes dra g on reve� d jV��q Signed itle: Date: FOR DEPARTMENT USE ONLY Application Accepted b Y'�^ Date Area Pit or Grout Inspection y r Date Final Inspection.by ' Date Additional Comments: 1, - ❑ Stk 4C&6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 Applicant- Return all copies o: Environmental Health Permit/Services 1601 E. Hazelton Ave.,YP.0. Box 2009,_ Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE ZPERMIT'NOj.INFO r EH 13-24{REV.t/9 5Y EH 14.29