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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209)'466-610 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 compli&V 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 ` / `G /h`a -R7, City ` {�J_ 1__ Lot Size PM Owner's Name Address CJ Z_[1�i& Phone �`�/ 7`�U Contractor Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ 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 I_l Other Ll Delta Depth of Grout Seal Type of Grout I I i Irrigation —..Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done E Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION t I DESTRUCTION INo septic system permitted if public sewer is I available within 200 feet.) ' Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms Character of sail to a depth of 3 feet: Water table depth J SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ P Method of Disposal Distance to nearest: Well Foundation Property Line 1 LEACHING LINE ❑ No. & Length of lines "" Total length/size I FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS 0 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 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 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 )aws`of California." The applicant mu c for all required inspection om lete drawing on reverse side. Signed X Title: Date: �.~2-3. I FOR DEPARTMENT USE ONLY Application Accepted by \knDate �"Z Area Pit or Grout Inspection by Date Final Inspec ion by Date r Additional Comments: 'r ❑ Stk 466-6781 Lodi -3621 ❑ Manteca 823-7104 ❑ Tracy 8309385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O.yBox 2005, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE EERM17'fNO.INFO CA+.EH 13-24(REV.F/nsl 1 EH 1426 v