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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-67,91 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. r Job Address City,- 7C- Lot Size �.e '! QPM Owner's Name _. Address Jl.- Phone.�__�' Contract e Address _ License Nar%� .1 Phon : TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT L]. DES ION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR Cl OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION _ AGRICULTUREWELL OTHER WELL PIT5ISUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I i Industriai ❑ Open Bottom ❑ Mame pia. of Well Excavation C-1 Domestic/Private L-1GravelPack Dia. of Well Casing _ I' Public f 1 Other ----I �cy Type of Casing Specifications I Delta Depth of Grout Seal i I Irrigation __ Apr Depth I Eastern �— -- Type of Grout Repair Work Done I] T Surface Seal Installed by of Pump _ H.P.__ -S) Well Destruction State Work Dane _ Well Diameter Sealing Material (top 501) Depth Filler Material (Below 50') T OF SEPTIC WORK: NEW INSTALLATION LI REPAIR/ADDITION I I DESTRUCTION [ I (No septic system permitted if public sewer is Installation will serve: Residence t available within 200 feet.) Commercial Other i � Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: c- SEPTIC TANK ❑ Type/Mfg ' Water table depth PKG. TREATMENT PLT. Ll Capacity No. Compartments Distance to nearest: WellMethod of Disposal Foundation Property Line _ LEACHING LINE X No. & Length of lines _ FILTER BED LJ Distance to nearest; Well ` E C � Total length/size rc I �.k- Foundation --L—I � Property Line 5- _ SEEPAGE PITS I I Depth Size Number SUMPS L1-`Distance to nearest: Well Foundation�` DISPOSAL PONDS ❑ Property Line 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: "1 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." The applicant must call for all required inspections. Complete drawing on reverse side, Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Pit or Grout Ins Date %� c .� —� Area Inspection by Date Final Inspection by Additional Comments: Date ❑ Stk 466-6781 El Lodi 369-3621 Il Manteca 823-7104Traqy -63 / Applicant - Return all copies to: Environmental Health Permit/Services 1601 E.❑Hazelton Ave., P O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE INFO AMOUNT REMITTED CK CASH RECEIVED BY DATE . EH 13-29IREV.t:nb � �� J ;IRM'T'NO. EH 1429 4 Cf^GL