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APPLICATION FOR PERMIT S r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES S'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 mads 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. s Job Address City Lot Size PM Owner's Name 4 Address 20 � Phone Con':ractor e se No.l Phone t r1 s vv TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYST R PAIR ❑ OTHER ❑ DIS'FANCE TO NEAREST: SEPTIC TANK AGULTUR LINES DISPOSAL FLD. PROP. LINE FOUNDATION ELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM ARE ONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation -- _-, .__-.._._...-. Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy ype of Casing Specifications ['1 Public [l Other ❑ Delta pth of Grout Seal Type of Grout _ I I Irrigation ---Approx. Depth I. I Eastern S ace Seal Installed by _ Repair Work Done ❑ Type of Pump P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material l8elow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION [1 REPAIR/ADDITION I I DESTRUCTION 11 (No septic system permitted if public sewer is av lable within 200 feet.) Installation will serve: Residence_ Commercial Other a-d Number of living units: Number of bedrooms r 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 LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size _ Number 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, state laws, and, rules and regulations of the San Joaquin Local Health Di1trict. 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 �/f 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- W tion laws of California." The applicant ust call for al quireinspections. Complete drawing on reverse side. Sigred X Title: Date: _J' ,19"0 1' ORD FUT. IJSE..ONLY. Application Accepted by ��. �,b, Date �`l l� Area Pit or Grout Inspection by Date_ Final Inspection by Date 1 Q %. ,. Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 f ❑ Manteca 823-704 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFE AMOUNT DUE AMOUNT REMITTED C SH WY RECEEIIVBY DATE PERMITCK# 'NO. EH 13.241!9EV.t/n51 s�� /' 13-1gro70EH 14-28 L !(J /