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I 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 welUpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address aU66 r Jfr// � e� �l t City1 V Lot Size PM Owner's Name tf�NJcl /o✓/ Address Phone Contractor Address License No. _Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ f PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ I -DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES t DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDE6U S TYPE OF WELL Y PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial --- D Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing + ❑ Dom s is/Private ElGravel Pack EJ racy Type of Casing Specifications nPublic'- 1_1 Other ❑ 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 ❑ -Well Diameter Sealing Material (top 501 1' Depth Filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATIQN REPAIR/ADDITION l I DESTRUCTION I 1 INo septic system permitted if public sewer is m� [ }Yravailable within 200 feet.) Installation w ____ill serve: 'Residence_ Commercial Other t � Number of living units: Number of bedroa s Character of soil'to a depth of 3 feet: c", Water table depth SEPTIC TANK ❑ Type/Mfg Capacity Q No. Compartments vim-- PKG. TREATMENT PLT. ❑ 4 Method of�D�i porsal - Distance to nearest: Well 6 Foundation Property Line L LEACHING LINE IN.. & Length of lines /,�T�al length/size Q d FILTER BED ❑ Distance to nearest: Well 11� Foundation Property Line Z0 - ' SEEPAGE PITS. I ) 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, statel4an rules and regulations of the San Joaquin Local Health Di$trict. 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 t- employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring of 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." rr The applicant must call for all required inspections. Complete drawing on reverse side. 1 iii Sign X Title: Date: FO DEPA ENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Datd e D " I,. .- -,.. i Additional Comments: Ll Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 i 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 M SH RECEIVED BY DATE PERMIT NO. +�EH t4-28(REV.t i n 5)