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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 he+eby 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. / r Job Address City Lot Size M Owner's Name Address Phone ' 44 �. Contractor S ense No. Phone9-21 TYPE OF WEL /PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. 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 1-1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation _-Approx. Depth I i Eastern Surface Seal Installed by x _ Repair Work Done ❑ Type of Pump H.P. State Work Done= Well Destruction ❑ Well Diameter Sealing Material {top 50'1 r ;` Depth Filler Material (Below 507) TYPE OF SEPTIC WORK: NEW INSTALLATION HLPAIR/ADDITION l 1 DESTRUCTION I I (No septic system permitted if public sewer is '• . available within 200 feet.) Installation will serve:. Residence Commercial_ Other r Number of living units: Number of'b'edrooms Character of soil to a depth of 3 feet: Water table depth I. SEPTIC TANK ❑,. Type/Mfg ' Capacity J No. Compartments PKG. TREATMENT PLT. ❑ ,�}} Method o Disposal Distance to`nearest: Well 'Foundation., ,9 Property.Line_ LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑. Distance to nearest: Well 17 O+oundation Property Line I' 1 . SEEPAGE PITS I 1 Depth b h2.6 Property ` SUMPS '"0 Distance to nearest: Well foundation , Property Line_. L4_ DISPOSAL PONDS CIC�(� T ( _ I hereby certify that I have prepared thls application and that the work will be done in accordance with San Joaquin county ordinances, state taws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signal6re 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." Contractors 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 all reqpk9d in cti s. Complet r on reverse side. Signed X itis: Date: S � r FOR DEPARTMENT USE ONLY Application Accepted by Date < ! Area r rout Ins cti n.by w w pate Final inspection byDate—�� Additional Comments: I � �/��L El Stk 466-6781 El 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 INFO AMOUNT DUEL AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT•NO. [� r +.EH 13-241REV.siHe1 EH 14-26 764