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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON 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. Cit Lot Size _ PM Job Address / C� Q ~ �) . Address D ts' Phone 0 S � +� Owner's Nart� Contract Address Q °r License No.32 226- Phone �Q I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER .17] DISTANCE TO:NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. Y PROP. LINE FOUNDATION AGRICULTURE WELL, OTHER-WELL^ PITS/SUMPS L M I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca pia:of Well Excavation Dia. of Well Casing r LJDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Type of Grout I`I Public ; I ' Cl Other ❑ Delta Depth of Grout Seal YP ' � ` rox. De th l I Eastern Surface Seal Installed by- 11 Irrigation 'I --APP p. Repair Work Done ❑ Type of Pump H.P. State Work Done._ Well Destruction ❑ Well Diameter Sealing Material Itop 501 - Depth ler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION `REPAIR/ DDITION DESTRUCTION l 1 (Nailableo sept within permitted if public sewer is Installation will serve: Residencecommercial— Other f Number of living units: —I— Number of rooms to Character of-soil two a depth of 3 feet: Water table depth SEPTIC TANK .❑ Type/Mfg Capacity No. Compartments PKG.-TREATMENT P.LT. ❑ Method of Disposal .r Distance to nearest: Well Foundation Property Line LEACHING LINE �NO. & Length of lines _ r Total length/size ' ! �, FILTER BED ❑ Distance to nearest: Well .S Foundation Property Line SEEPAGE PITS i I Depth �f Size _ Number SUMPS L1 Distancetonearest: 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 agant'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.co_n`tracting_signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons.!'uIoject to workman's compensa- tion laws of" ifornia. f Y ^ ---- l The applicant t call for II re uir inspections. Complete drawing on reverse iPe, Signed ' Date: ry N FOR DEPARTMENT USE ONLY ti Application Accepted by Date Area� Pit or Grout Inspection by Date Final Inspection by Data ` 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 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO 7 CASH + EH 13.241R' .1lR51 EH 14-28