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rw _ 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. f Job Address /� e740City Lot Size PM Owner's Name Address 00, t Contract Addres (Q ..C.: L'scense Pho TYPE OF WELL/PUMP: NEW WELL ❑ _ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES SAL FLD. PROP. LINE FOUNDATION AGRICU L OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL P M AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open.Bott ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Pack ❑ Tracy Type of Casing Specifications "V M 1 Public Other, ❑ Delta Depth of Grout Seal Type of Grout _ I i Irrigation _._Approx. Depth I I Eastern Surface Seal installed by `t Repair Done ❑ Type of Pump x H.P- State Work Done estruction 17 Well Diameter Sealing Materialltop 50'1 \( t Depth Filler Material (Below 50') �y TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIWADDITION 1.1; DESTRUCTIO (No septic system permitted if public sewer is I available within 200 feet.) j Installation will serve: Residence— Commercial— Other--, Number of living units: Number of bedrooms T Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK1 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line t LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 1 SEEPAGE PITS 1.1 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 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." t The applican ust call for all re wired inspections. Complete drawing on reverse side. Signed X Title: Date: r F R DEPARTMENT USE ONLY ' Application Accepted by �- r Date Area ; n —7 , Pit or Grout Inspection by $ Date _'Final Inspection by Date Additional Comments: ? — S ❑ Stk 466-6781 ❑ Lodi 369 1 ❑ Manteca 1123-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY PATE PERMIT'NO. + EH13-21[11-29 REV ir EH .1/n 51 _15 �! 101 G f•