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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON 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 herLin 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. L� Job Address ` '� City "- t Size PM N. Owner's Name � � Lf Address Phone `� Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DIST NCE TO SEPTIC TAtNK. SEWER LINES DISP 0. PROP. LINE FO N AGRICULTURE WELLOTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL M A ONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom teca. ia. of Well Excavation Dia. of Well Casing i LI Domestic/Private 1-1Gravel Pa IDTracy Type o Specifications F1 Public 'Cl r F] Delta Depth of Grout Seal Type of Grout _ I I Irrigation _.._..Approx. Depth i I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump' H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth I Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l'1 REPAIR/ADDITION l I,-DESTRUCTION (No septic system permitted if public sewer is r available within 200 feet.) Installation will serve: Residence LCommercial_.r Other Number of living units: Number of bedrooms e depth Character of soil to a depth of 3 feet: Water table de p SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance'to nearest: Well ' = Foundation PropertyLine t LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance.to nearest: Well Foundations Property Line h SEEPAGE PITS [ I Depth Size Number i SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS. ❑ I I hereby certify that 1 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: "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 California." i The applica must call for.all requ pections. Complete drawing on reverse reverse side. Signed Xk6qi Title: G� Date: ! FOR DEPARTMENT USE ONLY GJ o Application Accepted by i __ Daie �� rea s _ _ Pit or Grout Inspection Date Final Inspection b Dat Additional Comments: !ZZ111,?I 0�1/ ❑ Stk 466-67131 ❑-Lodi 369-3621 O Manteca a23-7104 O Tracy 1335-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED A RECEIVED BY DATE PERMIT'NO. NFO +.-EH 13-24(REV, /is 5) v G1 5f4/ fH 14-2$