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4 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 Districts oe Job Address r City -0 US PM Owner's Name �' `' Address 97 Phone Contractor Vu)w� .Address icense NoPhone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTR CTION ❑ 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 l Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout C I 1 Irrigation —.-Approx. Dept l I Easternrface Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 V TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION 1 1 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 ❑ No. & Length of tines Total length/size FILTER BEI] ❑ Distance to nearest: Weil Foundation Property Line SEEPAGE PITS i I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby c i 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 egul tions of a San Joaquin Local Health District. Home o er or licens a nt's signatur rtifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ a y per on in s ch n as ec me sub j t to workman's compensation laws of California." Contractors hiring or sub-contracting signature certifies t fol wing: ' cert y t i t Orman of the work for which this permit is iss I shall employ persons subject 10 workman's compensa- tion taws o rnia." The ap is u t a r e i ct ns. mplete drawing on ver Signed Title: Date:U U FpPARTMENT USE ONLY Application Accepted by L4 / DateArea !;2/ L� Pit or Grout inspection by Dat Final Inspection by Date Additional Comments: ❑ Silk 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 INFO AMOUNT DUE AMOUNT AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. +.EH13-24iREV.�/nW 3s•00 �� "7_^77„Q� ?4- 11 EH 14-26 I !!�� OO L