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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone {209} 466-6781 f € PERMIT EXPIRES 1 YEAR FROM DATE ISSUED JComplete 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 CityN. ot Size PM 4 Owner's Name Phone Contractor � Address/.-�G�dllS�i�_ _/Ct�.License No.407�.kSPhon ' TYPE OF WELL/PU P: 1 NEW WELL ❑ WELL REPLACEMENT ❑ STRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM_ REPAIR ❑ s- OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK. R LINES ISPOSAL FLD.-, PROP. LINE " FOUNDATION AGRICU RE WELL OTHER WELL `. PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CO UCTION SPECIFICATIONS . ❑ Industrial ❑ Open Bottom ❑ Manteca a, of Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel'Pack ❑ Tracy _ Type of Casing Specifications ❑ Public ❑ Others w.� x ❑ Delta . Depth of Grout Se �^ Type of Grout ❑ Irrigation �pprox.'Depth i}❑l tern Surface Seal Installe Repair Work Done El Type of Pump H.P. Stat Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Motetial (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION K(No septic system permitted if public sewer is ti available within 200 feet.) V� Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms Character of soil to kdepth of 3 feet: " �` Water table depth SEPTIC TANK ❑ Type/Mfg i+ Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal t Distance to nearest: z Well - Foundation Property Line I LEACHING LINE D No. &;Length of lines' } Total length/size ' ~ FILTER BED ❑ Distance to nearest: f Well Foundation t Property Line ' SEEPAGE PITS ❑ Depth) Size $ Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared'this application andthatthe work will be done in accordance with San Joaquin county ordinances, state laws, and rulgs and regulations of the San Joaquin'Local Health District. �. Home owner or licensed agent's signature certifies the followio: "I certify that in the performance of.the work for which this permit is issued, I shall not employ any person in such manner ag to become subject4o•workman's compensation laws of California.".,Contractor's hiring or sub-contracting signature certifiesrthe following: "1 certify that ih.the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion 1a 1 1. � �-- •1 The app nt rrlust call all requ Qd r ' ctions. Com s to drawing on reverse side. Signed ��.Date: FOR DEPARTMENT USE ONLY Application Accepted by tit t c" Date Area `•�. Pit or Grout Inspection by ` to Final Inspection by Date/ 7 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104.. ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Servioes 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ;. FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT`NO. INFO + EH1 3241RE11.1/0 5) 3� _J C` 25 EH 14.29 J