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APPLICATION FOR PERMIT r- SAN JOAQUIN LOCAL HEALTH DISTRICT , 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 NX) 13 PERMIT EXPIRES 11-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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. �` Job Address City Act Size PM Owner's Name �• ARM dress -� j � _ ��'' Phone Contractor ( Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PICS/SUMPS v 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 n Public ❑ Other 1-1 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 t Weil Destruction ❑ Well Diameter Sealing Material (top 501 Depth I Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I'1 REPAIR/ADDITION I 1 DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) Installation'will serve: Residence y Commercial— Other—k Number of living units: Number of bedrooms 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 i Distance to nearest: Well Foundation Property Line j LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line I SEEPAGE PITS [ I Depth r Size Number SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ t 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 Joaquid Local Health District. Home owner or licensed agent's signature certifies the following: 1 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 applicaA must call for all req fired inspections. Complete drawing on r verse side. Signed X Title. d Date: DEPARTMENT USE ONLY Application Accepted by 6G, A Date Area Pit or Grout Inspection by Date Final Inspection by t 7/1 Date-3 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 45201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMWNNyO. + EH 1324iREV.I/n51 ?rho Lq' L2 & P—�// EH 14-2fS v a �f/ Q 000 .J(b