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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 TYEAR 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 SQ �^� �1 �-`- Y Lot Size AIP 016 PM Owner's Name Address ,0h /t Phone Contractorr, ..At Address License N y/ YwS' Phone �Z TYPE OF WELL/PUMP: NEW WELL E WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION &-r SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK .-_ SEWER LINES DISPOSAL FL � D. d1V4-PROP. LINE J�` FOUNDATION _� AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS [I� Industrial pen Bottom ❑ Manteca Dia. of Weil Excavation Dia. of Well Casing A-bomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing- -1 [l Public ❑ Other ❑ Delta Depth of Grout Seal ype of Grout I E Irrigation --:..Approx. Depth I I Eastern Y Surface Sea] Installed by - Repair Work Done ❑ Type of Pump er H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Materia] (top 50') Depth Filler Material (Below 501 T PE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR)ADDITION l I DESTRUCTION € I (No septic system permitted if public sewer is available within 200 feet.) Installation wi Residence__ Cfb ercial_ Other Number of living units: r orooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation erty Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED El Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size #" _ Number SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 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." The applicantmus coli for all required inspections. C pl to drawing on reverse side. Signed X Title: Date: ` a f Oft DEPARTMENT USE ONLY Application Accepted by 11 (� Date /o_;2J Area �Q z Pit or Grout Inspection by Date Cd` a Final Inspection Date J3� y r GQ-f � Additional Comments: ❑ Stk 466-6781 ❑ Loi 369-3621 ❑ Manteca 823-71 ❑ Tracy 5-fi385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 IFEENFO AMOOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT*NO. + EH EH t4-241REV.