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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone 12091 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 �i Lot Siz PM Owner's Name' x Address Phone W Contractor ('f" . Address License NoA lvlza Phone 1- TYPE OF WELL/PUMP: NEW WELL ❑ WELL RE LACEMENT ❑ DESTRUCTION ❑ + PUMP.INSTALLATION ❑ SYSTEM REPAIR ❑ = OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS a INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private El Gravel Pack rj�Tiacy Type of Casing Specifications ❑ Public C) Other Delta Depth of Grout Seal .---Type of Grout ❑ Irrigation 9 _Approx/:Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done � � t t} Well Destruction ❑ Well Diameter Sealing Material (top 50'1 ++ltA»e-- Depth Filler Material (Below 501 1 -Na\ C111 O TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is �1 1 vailable within 200 feet./ Installation will serve: Residence!1 Commercial_ Other 1 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet- Water table,depth" SEPTIC TANK ❑ Type/Mfg Capacity 12 No!ComEsartmmeents PKG. TREATMENT PLT. ❑ " '' k _ eft otl of Disposal Distance ti nearest: Well Foundation JFProperrtpLine " LEAGHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line F ' SEEPAGE PITS D Depth Size Numbert SUMPS Ll Distance to nearest: Well Foundation Property Line A' DISPOSAL PONDS ❑ 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 Cali i1 The 4 plic t call far all r ed in16pe ns. Complete drawing on reverse side. Signed Title Date: f 2— i ' F EPARTMENT USE ONLY Application Accepted Date ��.2. Area Q� Pit or Grout Inspects y `r Date Final Inspection by Date A,7 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 2008, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT N0. + EH 13.24(REV.I/e51 EH 14-4-28