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APPLICATION FOR PERMIT 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. J— - Lot :�- Job Address City Size _ PM Owner's N e M "� Address v ✓ Phone Contractor ess ' 7 D �.Ya,IC l / License No f ,1one TYPE OF WELL/PUMP: 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 INTE DED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ 1pestrial _0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private E7 Gravel Pack ❑ Tracy Type of Casing Specifications ElPublic ❑ Other Delta Depth of Grout Seal Type of Grout ❑ Irrigation ��pprox. Depth East n Surface Seal Installed by Repair Work Done Cde Type of Pump H.P. '� Mate1!ocl�Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) S• Installation will serve: Residence_ ,Cortlfnercial_ 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 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest::_ Well Foundation Property Line l; LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify th arepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and re ions of the S Joaquin Local Health District. Home ow, r orlicensed agent's ignature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ y person in such mannp2 to become subject t5elrk rr ' mpensation laws of California."Contractor's hiring or sub contracting signatu certifie the following:"I certify in the r ce ich this permit is issued,I shall employ persons subject to workman's compen tion 'Tp sof California. The a plicant t require 1 plate g on re i Signed v Title: Date: FO D PARTMENT USE ONLY JJ Application Accepted y Date 2'z Area Pit or Grout Inspect Date Final Inspection by tti Date Y 4 Additional Comments: ❑ Stk 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 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT"NO. + EH 13-24(REV.I(85) EH 14-26