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APPLICATION FOR PERMIT ` SAN JOAQUIN LOCAL.HEALTH DISTRICT �. 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7 YEAR FROM DATE ISSUED t r (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. 1962 for well/pump and the Rules and �Regulations sooff the San Joaquin Local Health District. r�� r r 1QI`v� Joh Address r u City Lot Size L50 X,35D PM Owner's Name Address f a Phone "� q Contractor € . Address o �5 / . License No. v��0e?1.3 Phone TYPE OF.WELL/PUMP: V NEW WELL A WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 100 SEWER LINES DISPOSAL FLD./00 PROP. LINE it FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USER 9 TYPE OF WELL PROBLEM-AREAN CONSTRUCTION SPECIFICATIONS ElIndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing i f Domestic/Private Gravel Pack Tracy Type of Casing JP C, Specifications e - ❑ Public ❑ Other ❑ Delta Depth of Grout Seal ZiM Type of ut ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by n Repair Work Done ❑ Type of Pump H.P. State Work Done f(J� Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 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. ❑ I Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth I Size Number SUMPS El Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ A ..I �4 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 1 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 vrorkman's compensation laws of California."Contractors 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." P The applicant 4ust call for all requi inspections. Comple a drawing on r rse side. i Signed 1 Title: Date: f + F R PAR ENT USE ONLY Application Accepted by Date p Area 0 i Pit or Grout Inspection by Date �" Final Inspection by Date Additional Comments: i ❑ St F. 466-6781 ❑ Lodi 389-3621 ,❑ Manteca 823-7104 + ❑ Tracy 835-6365 Ag.1,.zant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CA _ RECEIVED BY DATE dPER—MIT•`NaO. + EH 13-24{REV.,/05) ' - EH 1428