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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address City Lot Size PM t Owner's Name ' Address Phone Contractor " ' > Address �y� Cn� License No. s7�" f Ph no e TYPE OF WELL/PUMP: NEW WELL ❑ . WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ _ w OTHER ❑ r DISTANCE TO NEAREST:`SEPTIC TANK SEWER LINES DISPOSAL FLD: PROP. LINE FOUNDATION " "' f 'AGRICULTURE LWEL'L`"—`—OTHER-WELL _- PITS/SUMPS INTENDED USE TYPE OF WELL PR CONSTRUCTION SPECIFICATIONS # ❑ Industrial ❑ Open Bottom ❑ Manteca ' Dia.-o avation Dia. of Well Casing 0 Domestic/Private ❑ Gravel Pack ❑ Tracy ~ Type of Casing'. Specifications t"1 Public f7 Other ❑ Delta Depth of Grout Seal a of Grout _ I I Irrigation _-Approx-.Depth I I Eastern`y Surface Seal Installed by a Repair Work Done ❑ Type of Pump H.P..__ State Work Done_ w F Well Destruction ❑ Well Diameter Sealing Material (top 50') p r� ! Depth _ + Filler Material (Below 50') �1 TYPE,OF SEPTIC WORK_ NEVI(-INSTAL'LA"ON`1.1-`REPAIR/ADDITION DESTRUCTION I I INo septic system permitted if public sewer is '< : # available within ZDO feet.? Installation will serve: Residence,-j -Commercial` Other ��T/�J� Number of living_units __L_____fYumber of bedrooms' Character of sail to a depth of 3 feet: F Water table depth SEPTIC TANK ❑ j Type/Mfg '' Capacity No Compartments PKG. TREATMENT PLT. ❑ w ~' " - Method of Disposal ; s yDistance to nearest: Well Foundation Property Line LEACHING LINE mss' No. &.L ngth of lines -_'�,C �d Total'length/size we"4T FILTER BED LJDistance to nearest: Well f Foundation'.!$?!!,3r— Property Line 7'0 SEEPAGE PITS Depth E 2 1✓ Size .___ Number SUMPS L� Distance to nearest: Well t*'W7— Foundation 60 Property Line 70 _ DISPOSAL PONDS ❑ I hereby certify that'( 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:2A-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." I f The applicant must c r all requ' d ins s. Complete drawing on reverse side.- Signed ide:Signed X Title. �'�� -.. Date: t FOR DEPARTMENT USE ONLY Application Accepted by , Data ' Area �� 1 i Pit or Grout Inspection Date Final Inspection by wv" Date ! 9- I .. ,,, o Additional Comments: ,/VO ..� j t Gk+- l , f++- [ h" "n-I ht,� fj i�xk 1 J ❑ Stk 466-6781 ❑ Lod 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 �N Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I FEE I INFO AMOUNT DUE AMOUNT MITTED CASH RECEIVED BY DAT£ PERMIT NO. + EH13-241REV.5/H51 - EH 16-28 (J