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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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. I Job Address 4ZA<f5" Cit Lot Size PM r Owner's Name w Address .r �� Phone Contractor Address_ I Icense Phan TYPE OF WELL/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 PITS/SUMPS j INTENDED USE TYPE OF WELL _ PROBLEM AREA CO TION SPECIFICATIONS 1I ❑ Industrial ❑ Open Bottom ❑ Mantec Dia- of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack racy Type of Casing Specifications FI Public ❑ Other t ❑ Delta Depth of Grout Seal Type of Grout I Irrigation _U- pprox{ Depth I I Eastern Surface Seal Installed by Repair Work Don Type of Pump H.P. State Work Done_ ! Well De +on ❑ Well Diameter` Sealing Material {top 54'1 a Depth Filler Materia! (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 1_]_DESTRUCTIOfbh�!1No Septic system permitted if public sewer is s '`available within 200 feet.) Installation will serve: Residence_ ..Commercial_ Other '. Number of living units: Number•bf.bedrooms Character of soil to a depth of 3 feet: 00 Water table depth SEPTIC TANK Type/Mfg = ----:-- * Capac VL . No. Compartments PKG. TREATMENT PLT. ❑ i t i 1 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line : r t y . SEEPAGE`PftS. I 1 Depth 1 Siieti r Number SUMPS,' nea D Distance to rest: Well Foundation Property Line s a 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." 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 applicant st call for all required inspections. Complete drawing on reverse side. f Signed X Title: Date: FOR DEPARTMENT USE ONLY r 4 Application Accepted by "i r •.� Date t0— Area i Pit or Grout fnspectio b f Data Final InspectionbyDate Additional Comments 0 Stk 466-6781 ❑ Lodi 369-b621 ❑ 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 n FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'No. INFO SH + EHt3-241REV.1iH5i 3� �VJ✓ � � Ap EH 14.26 J �z�/J[J ` 7