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APPLICATION FOR PERMIT I te, SAN JOAQUIN LOCAL HEALTH DISTRICT /1+ 1601 E. HAZE T QN AVE., STOCKTON, CA 4PR Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1 5 IPF,17 (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work ri� A� I�HA on made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1852 for well/pump and the Rules and a 'aMuin Local Health District. Jab Address City Lot Size Wa- PM Owner's Name to -fog, g��+l lllf Address Phone i I Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIONJX PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL PLO. 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by r Repair Work Done ❑ Type of Pump H.P. State Work Don Well Destruction ❑ Well Diameter Sealing Material (tome �p 3 Depth Filler Material {Below 501 r TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic stem p y permitted if public sewer is available within 200 feet.) r taflatis 11 serve: Residence_ Commercial— Other Number of living units: Number of bedrooms f Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments P_KG. TREATMENT PLT. ❑- Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE LINo. & Length of lines Tota! length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ r 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, 1 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 Cali nia." i The applicant c II for all req ire ctions. Complete drawing on reversside. Signed Title: Date: 2, F R DEPARTMENT U ONLY 1 Application Accepted by Date `7 Area Plt'or Grout Inspection by /I Date Final Inspection by Date Additional Comments:. rG e 0 Stk 466-6781 ❑ Lodi -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 REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH 1&24(REV.i/e 51 �� 6�/„ -16—S-) 197-1 EH 1428 'u