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APPLICATION FOR PERMIT � SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 486-6781 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. 11362 for welUpump and the Rules and Regulations of the San Joaquin Local Health District. Cit --; Lot Size PM Job Address y i Owner's Name �p -Lem Address f' Phone Contractor Address Lr- License No,* 91p Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES r- DISPOSAL FLD. LINE FOUNDATION AGRICULTURE WELL.. OTHER PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTI CIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. ell Excavation y�Dia. of Well Casing ❑ Domestic/Private ,'y.❑ Gravel Pack ❑ Tracy ype of Casing Specifications 171 Public "`' '{1 Other Cl D Depth of`Grout Seal Type of Grout I I Irrigation ! —.Approx. Dept Eastern Surface Seal installed by Repair Work Done i❑� Type of Pu H.P. State Work Done Well Destruction E_'. Well Diameter ' Sealing Material (top 56' ' V" epth : Filler Material (Below 50'1 TYPE OF SEPTIC WORK:'' NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION No septic system permitted if public sewer is t vailable within 200 feet.) Installation will serve: Residence)_ Commercial Other t-.-. - Number of living units: r Number of bedrooms Character of soil to a depth of 3 feet: f � ' Water table depth SEPTIC TANK ❑ Type/Mfg ! Capacity f No. Compartments PKG. TREATMENT PLT. ❑ ' # ^' Method of Disposal Distance to nearest: Well Foundation'-' ! f Property.Line LEACHING LINE ❑ No. & Length of lines I : Total'.length/size FILTER BED ❑ Distance to nearest: 1 Well r �Founda'tion Property Line SEEPAGE PITS I I Depth t 1 Size Number SUMPS ❑ 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: "t 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 ust call for all required inspections. Complete drawing on reverse side Signed Title: Date: FOR ARTMENT USE ONLY ��'` Application Accepted by Date � Area Pit or Grout Inspection by Date Final Inspection byDate Additional Comments: r C_ � � t't �-e + r �-� � l4, a ❑ Stk 466-6781 ❑ Lodi 369.3621 ❑ Manteca 823-7104 ❑ Tracy 835-638 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., A 95201 ) y FEE AMOUNT DUE AMOUNT REMITTED CK CASH RE=CEIVED BY DATE PERMIT'NO, INFO �n! .r.EK 13-24(REV.I/H51 10(to i EH 14-28 fff J