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APPLICATION FOR PERMIT I SAN 'JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL I ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED w (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 complianc%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. k Job Address 3 t7 City Lot Size PM ' Phone b2l SY Owner's Name Address License No. Phone Z- Z Contractor's Name - TYPE OF WELL/YMP: `' '' NEW WELL Ca' WELL REPLACEMEN DESTRUCTION ❑ _' PUMPINSTALLATION � , SYSTEM REP R LJ OTHER Cl SEWER LINES DISPOSAL FLD. PROP, LINE DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL PITS/SUMPS ' F f FOUNDATION A CULTURE WE F INTENDED'USE TYPE OF WELL PROBLEM ARE CO„ TRUCTION SPECIFICATIONS ❑ industrial ❑Open Bottom ❑ Manteca of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Graves Pack ❑ Tracy Type Casing Specifications ❑ Public ❑ Other ❑ Delta Depth o out Seal Type of Grout ❑ Irrigation --Approx. Depth El Easter Surface Sea . stalled by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing^Matepal (top 50'1 r�r _ Depth"' *� r, Filler Material iBelow'50'1 • TYPE OF'SEPTiC WORK: NEW INSTALLATION 11 REPAIWADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is v vailable within 200 feet.) ot1 'Installation will serve: Residences Commercial_ Other [� Number of living units: Num b0er 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 A (} Distance to nearest: Well Foundation Property Line �J j LEACHING LINE ❑ No. & Length of lines Total length/size +� r FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth E Size Number SUMPS 11Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ t that the work will be done in accordance with San Joaquin county ordinances, state laws, and I hereby certify that I have prepared this application 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,1 shall employ persons subject to workman's compense- t tion laws of California." r The applica ust1 ' /,call for all required inspections:'Complete drawing oil e�eir& side. �� - '� C_`` Date: Signed Title: r -- L ` FOR DEPARTMENT USE ONLY k r Application Accepted by Area n ` Date - Pit or Grout Inspection by Date--T- Final Inspection by - Date Additional Comments: ' ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 i 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 IT'110, INFO CASH .� + EH 13-24 iREV.101831 � � � p� !-lift-tZ. C 7�(- 3 `13 EH W28 __