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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 , PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I, v. (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." r 7 / ) Lor t Size Addr �� ( — PM Owner's Namec � . �-/__1 � �i -_ Addressc2 Phone Contract "7 Address ��7 r License No,: Phone TYPE OF-WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ �~ w DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Or 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 Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 501 Depth Iler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR DDITION ®--DESTRUCTION ❑ (No septic system permitted if public sewer is *s available within 200 feet.) Installation will serve: Residence'/Commercial_ ,Other Number of living units: -/-. Number of rooms, pC� Character of soil to a depth of 3 feet: Water table depth 0 of SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments \ V PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size .r FILTER.BED ❑ Distance to nearest: Well Foundation Property Line "1 SEEPAGE-PITS— "r'—Depth"--�a� "+ " "Size -" �` Nrmber Q SUMPS : ❑ Distance to nea�rfst:. Well '/.126 r Foundation Property Line DISPOSAL PONDS ❑ `-„w r }} I hereby certify that I have prepared-this appticatiori.and that therwork will be done in accordance with San Joaquin county ordinances, state laws, and rules„and regulations of the San Joaquin Local Health District. Horne 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 became 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 theo ,wrk fo?vvliich this permit is issued, I shall emptoy porsons subject to workman's compensa- tion`laws of California." �'� i 4 The.applicant st call for Areq 'redinspections. Cbmplete drawing on reverse side. Signed i ` - Title:— Date: FOR DEPARTMENT-USE ONLY Application Accepted IN ,Date, U Area Pit or Grout Inspection by ate inat Inspection by �Y/V `s Date Additional Comments: ❑ Stk 466-6781 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6386 .+ Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 �r . } FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH + EH M24 4REV.1/8 5) EH 14-26