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Ji jrR APPLICATION FOR PERMIT " SAN JOAQUIN LOCAL HEALTH DISTRICT d 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED :i !Complete in Triplicate) h ` 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 Distri ct. Job Address 1' r CitUy Lot Size Ll b M Owner's Name �I Address z !_-/ r Phone Contractor Address icense No. Phone / TYPE OF WELL/PUMP: NEW ELL ❑ I WELL REPLACEMENT F 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 •� r D Domestic/Private ❑ Gravel Pack EI Tracy Type of Casing Specifications 1`1 Public Cl Other Cl Delta Depth of Grout Seal Type of Grout . I I Irrigation —_Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction 71 Well Diameter t "Sealing Material (top 501 ` Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTAL I-IT' REPAIR/ADDITION I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial— =Other. i` Number of living units: -E— Number of bedrooms Character of soil to a depth of 3 feet: . x Water table depth SEPTIC TANK ❑ `.Type/Mfg 1�V___�`� Capacity- [_ No. Compartments k ✓(' i ICP— �IF' i, PKG. TREATMENT PLT. ❑' ' ,. ` Method of Dispo al Distance to nearest: Well L� Foundation �._,_- ; _...-._ Property Line LEACHING LINE ❑ No. & Length of lines �/g/� d _Total lengthlsize l FILTER BED ❑' Distance to nearest:•— =Well 104D, Foundation Property Line b 0 SEEPAGE PITS I I Depth Size Number UMP D Distance to nearest: Wel n Foundation Property Line 120 1SD POSAL 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 Diltrict. 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."Contractor's 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 applican st forAl require pections. Comp a drawing o ev rse side. _ Signed X Title: u Date:, F R DEPARTMENT USE ONLY Application Accepted by Date / Araa Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 523-7104 ❑ 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 REMITTED CASH RECEIVED 8Y DATE PERMIT-NO. +,EH 1 -24(REV.i/8 sl EH 144-28 it..