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� a APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1641 E. HAZE T ON AVE., STOCKTON, CA n 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. 1962 for well/pump and the Rules and Regulations of the San Joaquin C I Local Health District. Job Address I City Lot Size O, PM i Owner's Name Address Qt12a Phone I Contractor's Name cense Na. Phone TYPE DF WELL/PUMP: WEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP,11NSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE # '` FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications y ' ❑ Public fE ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation -L—Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump I H.P. State Work Done Well Destruction ❑ 110WeII Diameter Sealing Material [top 501 f Depth Filler Material Melow 50') } TYPE OF SEPTIC WORK-:)NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ iNo septic system permitted if public sewer is f available within 200 feet.) Installation will serve: Resi nce f Commercial^ the Number of living units: k Number of bedrooms ID I Character of soil to a.depth of 3 feet:- j` Water table depth SEPTIC TANK ❑r–Type/Mfg f Capacity — �*No. Compartments PKG. TREATMENT PLT. ❑ ,�' ""* Method of Disposal Distance to nearest: Well Foundation Property Line i LEACHING LINE D No: & Length of lines _ Total length/size j FILTER BED ❑ Distance to nearest: Well Foundation Property Line e , SEEPAGE PITS ' Depth Size Number SUMPS D Distance to nearest: well Foundation Property Line 1 DISPOSAL PONDS 111 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 j 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 applicant m s II for al wired inspections Complete drawing on reverse side. Q� Signed Title: lam/ Date: f 11 FOR DEPARTMENT USE ONLY I 43 Application Accepted by l� rt ` Date rea O Pit or Grout Inspection by Date f ~Final Inspection by Date /Z /6 • ` A Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 It Man 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE 1 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. +EM 134IREV.101831 EH -2 i