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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (20911= PERMIT EXPIRES 1 YEAR FROM DATE ISSUED )Complete in Triplicate) Application is heteby 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 Addresser 1`+z __ City Lot Size PM Owner's Namemw 46 a„ // _ Address Xkl eePhone Contractors moi= Address License No. Phone 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 AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications t� 1`1 Public Ll Other U] Delta Depth of Grout Seal Type of Grout--- I rout I i Irrigation — Approx. Depth i I Eastern Surface Seal Installed by Repair Work Done L7 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 1 I REPAIR/ADDITION ( I DESTRUCTION XiNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence X_ Commercial_ Other Number of living units: —I— 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 Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines__ Y Y w Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l 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, ai d 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, i shall employ persons subject to workman's compensa- tion laws of California." The applicant must call fo all re it d ins tions. Complete drawing on reverse side. Q Signed X Title: _fwd/// Date: FO ART USE ONLY Application Accepted by Date ;e i1AZ_r� D� Area / Pit or Grout Inspection by � Date Final Inspection by . G �Jy I�� Date t C Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3-621 ❑ Manteca M-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 4 FEE r INFO AMOUNT DUE AMOUNT REMITTED CK/H RECEIVED BY DATE qgPERMI�T'NO. + EEH 13-24 H 10-261REv.iiH51 .. �. �[�� 9v pa- 3