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_1 APPLICATION FOR PERMIT Ir SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joe uin 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 3 r` City- '"-12 f� Lot Size PM ill Owner's Name 5 Address J( Phone l a Contractor's Name License No._. `f V Phone 2 7 i TYPE OF WELL/PUMP: NEW WELL ❑ 1WELL REPLACEMENT ❑ DESTRUCTION L1 ` PUMP INSTALLATEON , -SYSTEM�"��P IR' S OTHER 171 �•7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE + ? FOUNDATION AGRICULTURE WELL OTHER WELD PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIG1ATIONS ❑ Industrial k ❑ Open Bottom ❑ Manteca Dia. of Well Excavation' Dia. of Well Casing X"Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public 1 ❑ Other ❑ Delta Depth of Grout Seal Type of Grout t Ll Irrigation ---Approx. Depth ❑ Eastern Surface Seal ln`stalled by . G Repair Work Done ❑ Type of Pump H.P. f 2 State WorkDorre 1 i Well Destruction ❑ Well Diameter Sealing Material (top 50'1 W i f Imo- .- --- --- -- .Depth--�—.Depth,- t !_ - --Filler Material (Below 50'-i-• { TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DlfSTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) y Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms { Character of soil to a depth of 3 feet: l Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PIT. ❑ Method of Disposal I Distance to nearest: Well foundation Property Line r '- LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED. i ❑ Distance to nearest: Well Foundation Property Line F I l [ SEEPAGE PITS ❑ Depth Size - Number kk SUMPS t < ❑ Distance to nearest: Well f 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. i; 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 Cal-ifornia." Contractor's hiring or sub-contracting signature 1 a 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." 1 -�. s: - - t. Y�......,. .... , Ar,. The applicants st call r all re qui ed iris c i ns. Complete drawing on reverse side. Signed v^ Title: Date: F DEPARTMENT USE ONLY �— Application Accepted by Date �" P Area � I I Pit or Grout Inspection by Date Fin I Inspection by Date—Y 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 r FEE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT`NO. INFO +EH 1324(REV.10183) EH 14-26 S I,