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a APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT z �^ 1601 E. HAZELTON ON AVE., STOCKTON, CA I "" t Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I e (Complete in Triplicate) W 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. Y _ Job Address City Lot Size 7/ 7 x l e v - PM Owner's Name Address Phone Contractor Pi Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM PAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEW LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRIC TUBE LL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA ONSTRUCTION SPECIFICATIONS LJ Industrial ❑ Open Bottom ❑ Manteca of Well Excavation Dia. of Well Casing El Domestic/Private El Gravel Pack ❑ Tracy Typ of Casing Specifications I`1 Public 1-1Other F1 Delta Depth f Grout Seal Type of Grout _ I I Irrigation _..Approx. Depth l I Eastern Surface ual Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 5 ') Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION I I DESTRUCTION fNo septic system permitted if public sewer is available within 200 feet.I 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 Capacity No. Compartments PKG. TREATMENT PLT. ❑ _ Method of Disposal �J Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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, 1 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 gust cal r all �irradd inspections. Complete drawing on reverse side. Signed X_ /� Title: �[�-> / r Date: FOR DEPARTMENT USE ONLY Application Accepted by Date _2 ,23-g--) Area U Pit or Grout Inspection by j /Date Final Inspection by - Date Additional Comments: �z/ alb ❑ Stk 466-6781 ❑ Lodi 369-3621 0 Manteca 823-7104 ❑ Tracy 635-6385 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 CK RECEIVED BY DATE PERMIT NO. + EH 13-24(REV.ri n5) — �_„j EH 14-2$