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r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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-3 City L Lot Size g *).ec- PM Owner's Name Address Phone w Contractor f Address 7 O lel^t, �� License-No. hone�YJ 6 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT,© D UCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES POSAL FLD. PROP. LINE FOUNDATION A ICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AR CONSTR ION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Di Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy of Casing Specifications 1-1 Public n Other F1 Delta Depth Grout Seal Type of Grout _ f,. 1 1 Irrigation Approx. Depth i I Ea rn Surface Sea nstalled by _ Repair Work Done Ll Type of Pump H.P. State Work Done Well Destruction ❑ Weil Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1 ) REPAIR/ADDITION I I DESTRUCTION (No septic system permitted if public sewer is !- available within 200 feet.) V1 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. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line r LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size Number SUMPS Ll 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 DFstrict. 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, 1 shall employ persons subject to workman's compensa- tion laws of California." i The appli ust tail f r all requir d 'nspeC' ns. Complete drawing on reverse side. Signed X Title: C / Date: / FOR DEPARTMENT USE ONLY ` Application Accepted by date Area 1 , Pit or Grout Inspection by Date Final inspection by ate Additional Comments: � Ma 43-7104 o.� 5r ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823 7104 ❑ Tracy 835-6385 uS v Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVEDBY DATE PERMIT NO. INFO CASH n ' +.EH13-24{REV,i i H sl �3 EH 14-28 ��11` llliii f IA33