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APPLICATION FOR PERMIT [7 `t SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 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 City Lot Size PM yL.Owner's Name A dress Phone ff r i Contractor_..-k F_ Address License No. Phone TYPE OF WELL/PUMP: w NEW WELL ❑ WELL 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 p ❑ Domestic/Private "'❑ Gravel Pack- 'DTracy Type of Casing Specifications 11 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation —�-Approx, Depth I i Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P, State Work Done_ I Well Destruction ❑ Well Diameter 'Sealing Material (top 50') Depth Filler Material l6elow 50'1 TYPE OF SEPTIC WORK:-.r NEW INSTALLATION 1-1 REPAIR/ADDITION I I DESTRUCTION (No septic system permitted if public sewer is " available within 200 feet.l 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 1 PKG, TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line Y LEACHING LINE s ❑ No. & Length of lines Total lengthAize FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth > Size Number SUMPS ' D- '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 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."Contractors 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 -ornia"' ^ } The applic nt ust call�ti.q re�nsVl omplete drawing on reverse side. ..� Signed X Title: FOR DEPARTMENT USE ONLY f r 0 Application Accepted by Date + Area Pit or Grout Inspectio yy� Date /Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: E vironmantal/Health Permit/Services 1601 E. Hazelton Ave., P./O�. Box 2009,rStk., CA 9520 .w `�`bU/✓11X.�$r� t f�fiY1Lc1 f 1�7�afrtGi>'!'►'1 J� ��0 /� FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO , t EH 13-21(REv.1/R5] 3 �S�- EH F4-28 o-