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APPLICATION FOR PERMIT SAN JOAQUI.N LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 City Lot Size PM f r Owner's Name T�-�•.. Address Phone Contractor Address� ( � 9Sz� LiceG�o. �� . Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION l33' SYSTEM REPAIR W---' OTHER ❑ DISTANCE TO NEAREST:.SEPTIC TANK' SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS i I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing, omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications v�lJ Cl Public %O hher Cl Delta Depth of Grout Seal Type of Grout _. . I I Irrigation 7pprox, Deptht t l Eastern Surface Seal Installed by - c� Repair Work Hone Type of Pump .._ .')U2{ H.P. / State Work Done aP,44 ^Q 4 Well Destruction ❑ Well Diameter +'v Sealing Material (top 50') Depth Filler Material (Below 501 - TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION i I DESTRUCTION l I (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 Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property.Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED El Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS ❑ 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 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 nner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the follo ' g: "I certi that In the performance a he work for which this permit is issued,l shall employ parsons subject to workman's compensa- tion laws of C ornia." The applica u c o all req :ed ' i plate (awing on rev s side. Signed Title: Date: F DEPARTMENT USE ONLY . Application Accepted by Date 3^ �-� 1 Area Pit or Grout inspection by Date Final Inspection by Date Z Additional Comments: ❑ Stk 466-6761 ❑ Lodi 969-3621 ❑ 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 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVEDBY DATE PERMIT NO. INFO CASH q n +.EH1 -26fREV.t/H5) N EH -28 4Smt Q, 3^�� •�0n L