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APPLICATION°FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA ` Telephone {2091 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 ee_ City Lot Size PM ��`d Owner's NamS//, ddress ! Phone e/r� Contractor2;?�& Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ _ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ ER ❑ ri DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES OSAL FLD. PROP. LINE FOUNDATION AGRICULTURE OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLE CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom anteca Dia. of Well Excavation Dia. of Well Casing n ❑ Domestic/Private ❑ Gravel Pa ❑ Tracy Type of Casing Specifications " ❑ Public ❑ r ❑ Delta Depth of Grout Seal Type of Grout s' i I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by mak. Repair Work e ❑ Type of Pump H.P. State Work Done Well ruction ❑ Well Diameter Sealing Material Itop 50'1 Depth Filler Material (Below 501 `I TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION I I DESTRUCTION INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other c _ J t 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` • I r LEACHING LINE ❑ No. & Length of lines Total length/size`. s FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth SizeNumber• w r SUMPS ❑ Distance to nearest: Well _Foundatiori f �Property.Line DISPOSAL PONDS ❑ �—:.�• .v.-..-:�.,. _ I 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 j 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 applicant must call o 11 r d inspections. Complete drawing an reverse side. Signed X Title: Date: 02C FOR DEPARTMENT USE ONLY j Application Accepted In Date-21) Area Pit or Grout lnspec ' n e Date Final Inspection by_�r� _ �; Date 7 'WC� Additional Comments: ❑ Stk 466-6761 Lodi 369-3621 ❑ Manteca 823-71 ❑ Tracy 835-6365 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 + EH13-24{flEV.i i n 5r � L/� - - - Eli 14-26 �7 h