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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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 ,timid herein escribed. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ruis'tn�f ions of the San Joaquin Local Health District. F�� ' a tl f�-C/r City ' Lot Siz ' "'aPM�.� Job Address �� "' P oon�ar/ Owner's Name Address t Q� 7 License NoolBorb Phone .A;5 O Contract Address < TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT LI DESTRUCTION LJ OTHER ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia of Well Casing ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications r ❑ Domestic/Private ❑ Gravel Pack D Tracy Type of Casing Type of Grout -- Y ["1 Public F] Other Cl Delta Depth of Grout Seal - 1 1 Irrigation _Approx. Depth l 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 ill Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR DDITION DESTRUCTION i I (No septic system permitted if public sewer is available within 200 feet.) installation will serve: Residence Commercial_ Other l Number of living units: J_ Number of ooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKC. TREATMENT PLT. 0Method of Disposal Distance to nearest: Well Foundation Property Line / ( 1 LEACHING LINENo. & Length of lines 5 Total length/size FILTER BED ElDistance to nearest: Well Foundation VO IF Property Line SEEPAGE PITS l I Depth Size Number SUMPS Ll Distance to nearest; T ,Well Foundation Property Line DISPOSAL PONDS ❑ 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 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." t The applicant mu t 11 for all re ired ' spections. Complete drawing on revers si r /l Signed X .tie: Date: FODEPARTMENT USE ONLY y� d Date Z~l y� Area Application Accepted by R �•, � Pit or Grout Inspection by Date Final Inspection b � Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7164 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95261 CK S FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO + EH 11144 rrEV.I/A5r lJ�I � �V "" � ��• l� `� G? EH 14-26 1