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APPLICATION FOR PERMIT I SAN JOAQUIN.LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 � PERMIT EXPIRES 7 YEAR FROM DATE ISSUED , (Complete in Triplicate) d 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 e made in compliance with San Joaquin C unty Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. s Jab Address 4 City � bw Lot Size ` I �oLe— � Owner's Name °Address Phone Contractor ` AddressJ� b� License No. Phone , TYPE OF WELL/PUMP: NEW EL L ❑ WELL REPLACEMENT T EJ DESTRUCTION EJPUMP.INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATIONA,RICCULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEMA'REA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation " r f Dia. of Well Casing I ❑ Domestic/Private El Gravel Pack ❑ Tracy Type of Casing g ❑ Public Specifications ❑ Other ❑ Delta Depth of Grout Seal Type of Grout a ❑ Irrigation _ApproxDepth ❑ Eastern Surface Seal Installed by I Repair Work Done ❑ Type of Pump, li P .ter�..W-.. • State Work Done_ Well Destruction ❑ Well Diameter. Sealing Material (top 50'1 Depth $ ! Filler Material (Below 50) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION' (No septic;system permitted if public sewer is Installation will serve: Residence � Commercial— Other -available within 200 feet.) Number of living units: Number of bedrooms i Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfgt Capacity No Compartments PKG. TREATMENT PLT. El of Disposal Distance tonearest: Well FoundationProperty Line � I � � LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 1 T-- 1 SEEPAGE PITS ❑ Depth Size Number ` SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I 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 far which th perrn[-is issued, I shall not f_ 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 theiperformance of the work for which this permit is issued,I shall employ persons sub'act to workman's com tion laws of California." I pensa- The applican ust call for all required inspections. Complete drawing on reverse side. t E )(Signed Title: Date: . FOR R.EPARTMENT USE ONLY Application Accepted by Date Pit or Grout Inspection by Date Final Inspection b f Date ilk I a q Additional Comments: l— 7 # l ❑ Stk 466-6781 ❑ Lodi 369-3621: ❑ Manteca 823- 104 ❑ Tracy 835-6313,5. g Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE ;AMOUNT REMITTEDCK y INFO i CASH RECEIVED BY DATE PERMIT''NO. t EH 13-241REV,t/851 EH 1426