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APPLICATION FOR PERMIT k SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SND (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 we11/pump and the Rules and Regulations of the San Joaquin Local Health District. r7 Job Address r City Lot Size PM _ II i Owner's Name Bob Address Phone {6 �( t,K37iY �•d. 5 gRJ5 6 Phone f Contactor a Address License No. TYPE OF WELL/PUMP: e NEW WELL ❑ WELL REPLACEMENT ❑ 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications fI Public n Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation .I"_Approx. Depth l I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction O Well Diameter Sealing Material atop 50'? Depth Filler Material IBelow 50.1 kc I TYPE OF SEPTIC WORK:. NEW INSTALLATION 11 REPAIR/ADDITION i IDESTRUCTION (No septic system permitted if public sewer is { � available within 200 feet./ n ` Installation will serve: Residence= Commercial_ Other �•`t V Number of living units —Number of bedrooms I u Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKC. TREATMENT PLT. ❑ 'i I Method of Disposal Distance to nearest: Well f=oundation Property Line LEACHING LINE ❑ 'No. & Length of lines Tota! length size FILTER BED ❑ ,Distance to nearest: Well Foundation ' Property Line SEEPAGE PITS l I Depth Size Number SUMPS CI 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, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: '4hcertify 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 workrflan'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 I .The applicant r all required inspections. Complete drawing Ln reverse side. Signed X i Title: buirl Dater is F DEPARTMENT USE ONLY 1 A Application Accepted by l A.v�_M -r MA-kw�C..N". Date Area l Pit or Grout Inspection by Date �ina1 Insrpa tion b! Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi -3621 ❑ Manteca 823-7104 ❑ Tracy 5-6385 Applicant Return all copies to:-environmental Health Permit IServffes 1601-E"Hazelton_Ave.;P.O. Box-2009,_Stk.,-CA.95201N—,—,J IFEE NFO AMOUNT DUE AMOUNT REMITTED '� ASN t y RECEIVED BY DATE PERMIT'NO. + EH 13-241REV. - EH 14-26 ` UUU