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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 12091 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. 1962 for well/pump and the Rules and Regulations of the San Joaquin Local Health District../ / Job Address /(r7�� /7rC � City �I c'l _ Lot Size PM Owner's Name Address �+ Phone I �!'' Contractor Address ) Z6i%,L e-'��. �ricense No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIONV PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE -_--T_ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Li Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation . Dia. of Well Casing F] Domestic/Private ❑ Gravel Pack 71 Tracy Type of Casing Specifications f`1 Public I 1 Other ❑ Delta Depth of Grout Seal _ Type of i r, Irrigation Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done L7 Type of Pump H.P. State Work Done Well Desiructson + Well Diameter _. Sealing Mate6al (top 50') NG Depth — �� -- Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i 1 DESTRUCTION { I INo Septic system permitted if public sewer is available within 200 feed Installation will serve: Residence Commercial__ Other Number of living units: Number of bedrooms „ Character of sail 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 LEACHING LINE Ll No. & Length of lines Total iength/size r-� FILTER BED ❑ Distance to nearest: Well._ Foundation Property Line E� SEEPAGE PITS I I Depth Size Number SUMPS t 1 Distance to nearest: Wel! Foundation Property Line DISPOSAL PONDS 11 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: "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.". The applican, f requiro i ns. Complete drawing on re rs rde. Signed X CfiI Title: �• �'' Date:FOR DEPARTMENT USE ONLY Application Accepted by / Date_ ^ � r�YArea r Pit or Grout Inspection by Date Final Inspection by.... Date rJ Additional Comments: ❑ Stk 466-6781 C1 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 AMOUNT REMITTED CK It INFO RECEIVED By DATE PERMITNO. S� CASH r EH 13-24(REV,r/n 5) �� EH 14-28 J ��iT1 - 7,29./ -� ��: 7