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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE.T ON AVE., STOCKTON, CA Telephone (209) 466-6781 rkC 4L7,r),k- 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. L e-9 Cit Lot Size,5-v PM Job Address 1 �/ Owner's Name d/ J eZAddress �� Phone Contractor Address License No. Phone .TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM RE IR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK EWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION i 'kGRICULTURE LL OTHER WELL PITS/SUMPS I' INTENDED USE TYPE OF WELL PROBLE AREA ONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom f ❑ Mantec Dia. of WellExcavation Dia. of Well Casing ❑ Domestic J Private ❑ Gravel Pack ❑ Tr Type of Casing Specifications r fl Public (1 Other Delta Depth of Grout Seal Type of Grout I I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump• H.P- State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I'1 REPAIR/ADDITION 1 1 DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ 'Other ; Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK -❑ Type/Mfg't. Capacity No. Compartments PKG. TREATMENT PLT. ❑ '4 Method of disposal Distance td nearest: Well Foundation Property Line it LEACHING LINE ❑ No. & Length of lines Total length/size r' FILTER BED' ❑ Distance to nearest:' -Well Foundation Property Line It i I i, SEEPAGE PITS I 1 Depth Size Number i r. 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, stale laws, and rules and regulations of the San Joaquin'Cocal 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." Contractors hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shalt employ persons subject to workman's compensa- tion laws of California." I The applicant must c f r i ons Complete drawing on reverse side. Signed Title: /��"��J" Date: FOR DEPARTMENT USE ONLY Application Accepted by Date 2 Area Pit or Grout Inspection to F' all Inspection by _ Date I Additional Comments: Tw,nuc,- U LJStk 466-6781 ElLodi 369-3621 ❑ Manteca '823-7104 ❑ Tracy 835-6685 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 C RECEIVED BY DATE PERMIT NO. + EH13.21(REV.1/µsl !_ O '��-IU �� _�.•7 L� EH t0-29 J