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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Appli6ation 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 Ad toss _ Ci 44�wlof Size PM � a Owner's Name /6/ Address Phor -5 -e-4 A00 1 11 Contract TYPE OF WELL/PUMP DISTANCE TO NEAREST: INTENDED USE ❑ Industrial ❑ Domestic/ Private FI Public I I Irrigation Address Seo /4cense Phonj�_7) NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER TYPF OF WFI I ❑ Upen Bottom ❑ Gravel Pack r _1711 Other — Depth PROBLEM AREA CONST SPECIFICATIONS ❑ Manteca Ia. of Well Excavation ❑ Type of Casing n Delta Depth of Grout Seal I I Eastern Surface Seal Installed by Repair Work Done Type of Pump H. P, State Work Done _ a Well Destru nr r ❑ . Weil Diameter Sealing Material (top 50') • .' Depth Filler Material 18elow 501 TYPE OF SEPTIC,,WORK: NEW INSTALLATION I l REPAIR/ADDITION i I DESTRUCTION No septic system permitted it public sewer is Installation will serve: Residence _ Commercial" _— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg PKG. TREATMENT PLT. ❑ " Distance to nearest: Well Dia. of Well Casing Specifications Type of Grout LEACHING LINE ❑ No. & Length of lines FILTER BED ❑ Distance to nearest: available within 200 feet.) Water table depth Capacity No. Compartments Foundation _ F - Well Foundation Method of Disposal Property Line Total length/size— Property ength/sizeProperty Line 8 SEEPAGE PITS I 1 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, state laws, and 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, 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: "1 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." The applicantc for II requ' inspectio Complate d a in 4 g an v rse side. } Signed X Q ��' Title: Date: �" rJ 6.0 R DEPARTMENT USE ONLY Application Accepted by Date ^ Area Pit or Grout Inspection by ate Final Inspection �Y DateAC� Additional Comments: _ _ %-IG ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8335-6395 Applicant - Return ail copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 +. EH 13-24 (REV. 1 i 115 EH 14-2e INFO A OUNIT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT•N0. k 5F