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APPLICATION FOR PERMIT I= SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED e 1" (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 O K City Kdt Size PM h Owner's Name S 7 2 019 Address d � _--_ Phone Contractor Address zWs of License No Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR W 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 ClOpen Bottom C-) MantecaDia. of Well Excavation Dia. of Well Casing ,,6rr XDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications r-1 Public ❑ Other C Delta Depth of Grout Seal Type of Grout ._ I I Irrigation �..Approx. Depth I I Eastern tace Seal Installed by _ Repair Work Done ,$� Type of Pump _ H.P, State.Work Done a E Well Destruction ❑ rWell Diameter Sealing Material (top 50') I ' Depth Filler Material (Below-50.)- TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION l I DESTRUCTION l I INo septic system permitted if public sewer is f 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 r7 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 l 1 Depth Size Number SUMPS Cl Distance to nearest: -Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 Di§trict. Home owner or licensed agent's signature certifies the.f6iloWing:A 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 io workman's compensatjon 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,1 shall employ persons subject to workman's compensa- tion laws of California." The applica t call far all required ins coons. omple drawing on re side.,- 4 Signed X Title: "r _ Date: i a7, R DEPARTMENT USE ONLY Application Accepted by _ Date Area i Pit or Grout Inspection by Date Final Inspection by�Z�o_ .--_ Date i Additional Comments: ❑ Sik 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 2005, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED_,— CAS INFO m RECEIVED BY DATE PERMi-r NO. a.EH13-244REV.iia5rEH -26 Owl y