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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 "t�"" 1�ti City Lot Size PM Owner's Name A4A"cldress l"f o 3$ V` A746U Phone 4V 1111 111t I Contractor� U Address License No. u Phone 2A V TYPE OF WELL/PUMP: NEW WELL ❑ MVVELI 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1'1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation --Approx. Depth I 1 Eastern Surface Seal Installed by _ Repair Work Done 0 'PAIC of Pump H.P. State Work Done_ Well Destruction Rl Well Diameter Sealing Material (top 50') �/ ,-► Depth J D Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) 0 Installation will serve: Residence_ Commercial__ Other ,n Number of living units: Number of bedrooms U• 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 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 C1 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, state11awan rules and ulations of the San Joaquin Local Health District. Home ow eiyor licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued,employ a p rson in manner as t ecome bject to workman's compensation laws of California."Contractor's hiring or sub-contractin certifies th f lowing: 'I c that' perform nce of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of alifornia. The appli I qu ed ion om to drawing oWevrside 1O Signed X � 9 Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by _ �.[„ Date Area -� Pit or Grout Inspection by Date Final Inspection by n Date 7 l3 g Additional Comments: ❑ Stk 466-6781 ❑ 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 INFO AMOUNT DUE AMOUNT REMITTED CKf ASH RECEIVED BY ��.DATE PERMIT'NO. a.EH 13.24(REV.1/x 5) / 6J EH 1128 /'