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APPLICATION FOR PERMIT SAN JOAO,UIN•LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 12091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . (Complete in Triplicateli. 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 S �LJ_�f/_I ! � L .City Lot Size_ PM Owner's Name;" C " Address Phone Contract Address -7(0-7Z 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 FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom Ll Manteca Dia. of Well Excav`a`tion Dia. of Well Casing y� ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth,bf Grout Seal Type of Grout v ❑ Irrigation ----Approx. Depth ❑ Eastern �rSurface,Seal Installed by Repair Work Done L2 Type of Pump H.P.-""' State Work Done Well Destruction ❑ Well Diameter LSea ing Material (top 50'),•. Depth " � � f? Filler Material (Below 501] TYPE OF SEPTIC WORK: NEW INSTAL LATION:❑. REPAIR ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is I .F %f 1 available within 200 feet.) Installation will serve: Residence /Commercial , Other j--- x <,Y4-,Numtier,of living units: —L�Number of rooms f - Character of soil to a depth.df 3 feet: . Water table depth /0 SEPTIC TANK �! Type/Mfg';" rr - - Capacity No. Compartments PKG. TREATMENTiPLT. ❑ ! i} �, r i � Method of Disposal Distance to nearest: Well Foundation ` Property Line S _ � LEACHING LINE gi�'-No. & Length of lines f y�,. Total length/size X FILTER BED ❑ Distance to nearest: flNell3 ( ,__' "'Foundation f(j P,roprty Line SEEPAGE PITS depth -Q-T Size Number~ SUMPS ❑ Distance to nearest: Well_"_�.QQ."___ Foundation Property Line TS 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 applicant st call fora req "ed inspections. Complete drawing on reverse aid ,T,;2 Signed Title: 1� f Date: Z�. w• -FOR-DEPARTMENT- -USE ONLY. _ - ,may; I Application Accepted by afn Date. Area kyY v r ' Pit or Grout Inspection by _Date- Final-Inspection-by_- - _ Date -- - - - r /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, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH K4 RECEIVED BY DATE PERMiVNO. •+ EH13-241REv.tin5Y EH 14-28