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APPLICATION FOR PERMIT j�� " ,t SAN JOAQUIN LOCAL HEALTH DISTRICT 13�O 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 �^' � j zi A gwl City Lot Size PM Owner's Name d ! / Address ''gl/ j de)2- Phone `Ol f2 y� Contractor-� Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACE NT ❑ 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 f'1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation --Approx. Deptj]_ I Eastern Surface Seal Installed by - AG Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter " Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) 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 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 District. Home owner or licensed is 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 sfich 4nner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the followA'Icehat in the pe ermance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of CalifoThe applicant mue ctions. Complete drawing on reverse sid Signed X Title: Date: �/ZQg4 =RTMENT USE LY / _ Application Accepted by Data l0 !�� Pit or Grout Inspection by Date Final Inspection by�' X_ -7Date-y' JV 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 AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH a EH 13-24 IREV.i i H 5) /` EH 14-26