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APPLICATION FOR PERMIT �Y a 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 ^^ � City Lot Size PM Owner's Name ) Address U 4 Phone03- 3 Contractor's Name c� ense No. Cs TYPE OF WELL/PUMP: NEW WELL ❑ Phone WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ✓ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industria! v Open Bottom ❑ Manteca Dia. of Well Excavation Domestic/Private ❑ Gravel Pack ❑ Tracy T Dia. of Well Casing Type of Casing Specifications Public ❑ Other �. Delta Depth of Grout Seal rrigation Type of Grout ---Approx. Depth Eastern Surface Seal Installed by 4plair Work Done Type of Pump H.P. State or one Well Destruction ❑ Wel! Diameter Sealing Material {top 50'1 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ Mo septic system permitted if public sewer is j Installation will serve: Residence` Commercial, Other available within 200 feet.) Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK Water table depth ❑ Type/Mfg PKG. TREATMENT PLT. ECapacity No. Compartments Method of Disposal Distance to nearest: Well Foundation Property Line �.\ LEACHING LINE ❑ No. & Length of lines FILTER BED ❑ Tota! length/size Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size SUMPSG DiNumber � 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 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 workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "1 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." The applica fust r all required inspectigns. Complete drawing on reverse std Signed4. Title: Date: FO EPARTMENT USE ONLY Application Accepted by � Date + , _' S� Area Pit or Grout Inspection by ate Final Inspection by -le .GG�y'=-�� Dat Additional Comments: ❑ Stk 466-6781 Q Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 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 CASH RECEIVED BY DATE PERMIT N0. +EH 13-24(REV.lojm) EH 1426