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` APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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 AddressZd: City Lot Size PM Owner's Name Address Phor) Contrac ."Address C � LC �S3C� " I icense Ph e&�X TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OT DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM A ONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom teca Dia. of Well Excavation '* Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pa ❑ Tracy Type of Casing Specifications * Public er 171Delta Depth of Grout Seal Type of Grout I I Irrigation _..Approx. Depth I I Eastern Surface Seal Installed by _ Repair v_vw one ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 r Depth Filler Material (Below 501 V TYPE OF SEPTIC WORK: NEW INSTALLATION I l RLPAIR/ADDITION I I DESTRUCTION (No septic system permitted if public sewer is E available within=200 feet.) Installation will serve: Residence_ Commercial_ Other Number 61(living units: Number of bedrooms Character of sdil 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. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS .1 1 ",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 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 applican ust call for all re ire�1 inspections. Complete drawing on terse side Si ed X Title: (/�/ dam! Date: FOR DEPARTMENT USE ONLY Application Accepted by Date ��-'a Area O Pit or Grout Inspection b Date Final Insp ion W Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3%21 ❑ Manteca 823-7104 O 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'N INFO CASH +.EH13.241REV.tiNa1 �\ -� EH 1/-2e u�•+" Q I F, Y .3