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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 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 /S 7Z 3Z City "^t' � Lot Size an.am PM ep Owner's Name Address7a Phone Contractor's Name � �SIJ _ License No. Phone s TYPE OF WELL/PUMP: NEW WELL ❑ WELL-REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑_ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES__. -DISPOSAL_FLO. PROP. LINE ' 'FOUNDATION WELL— OTHER WELL — "- PITS/SUMPS = " INTENDED USE -,TYPE OF WELL PROBLEMAREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing . ❑ Domestic/Private ❑ Gravel Pack ❑ Trac Type of Casing *'' Y YP 9� S pecifications ❑ Public ❑ Other ` p Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Dane ❑ Type of Pump H.P. •State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ {No septic system permitted if public sewer is W ' available within 200 feet.) Installation will serve: Residence_X Commercial_ Other k - Number of living units: —/— Number of bedrooms r Character of soil to a depth of 3 feet: Water table depth Q SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method-of Disposal Distance to nearest: Well Foundation Property Line1, `ter( LEACHING LINE )K� No. & Length of lines _ �'—' � Total length/sized s FILTER BED ❑ Distance to nearest: Welles Foundation h451 u' Property Line SEEPAGE PITS ❑ Depth Size—_ -Z'y Number- rt l - r SUMPS-i_�_ Maance4o-nearest=- Well .�! # - �_ Foundation Property. .------ _ _ 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 Disti�idt: 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 follo ing: "I certify that in the perfor ce of the work for which this permit is issued,I shall.employ persons subject to workman's compensa- tion laws of C ornia." The app II fora require pe on Complete drawing o�, erse side. Signed Title: Date: FOR DEPAR MENT USE ONLY Application Accepted by Date /,,}(. Area IJ /} Pit or Grout Inspection by Date Final Inspection by `'/ � llpate� � 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 2009, Stk., CA 95201 �►� t FEE INFO AMOUNT DUE AMOUNT REMITTED CK 11 CASH RECEIVED BY DATE : PERMIT"NO. +EH13-20 IREv.101831 EH 1428 V