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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 4Y 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 incompliance 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 ` Lot Size PM i 4 Owner's Nameess Phone �. t — alTqContractor ss nse No.1, 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 PITS/SUMPS \ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial ❑ Open Bottom C] Manteca r Dia- of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'] Public ❑ Other C 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 1 Well Destruction © Well Diameter _Sealing Material (top 50') 1 Depth Filler Material (Below 50'1 TYPE OF SEPTIC.WORK: NEW INSTALLATION Y REPAIRlADDITION i I DESTRUCTION I 1 (No septic system permitted if public sewer is it Iavailable within 200 feet.) Installation will serve: Reidence ' Commercial Other �} 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 Dis osal Distance to nearest: Well v._(�''ftbandation Property Line f �} LEACHING LINE ❑ No. & Length of lines T al length/size FILTER BED ❑ Distance to nearest: Well -4 Foundation Property Line t SEEPAGE PITS I I Depth _ L Size Number '+ SUMPS ❑ Distance to nearest: WOI ' Foundation) Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with Sart 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,1 shall employ persons subject to workman's compensa- tion laws of California." 1 The applicant ust ca for all re inspections mplete drawing on re It side. - Signed X Title: I - Date: FOR DEPARTMENT USE ONLY f '' Application Accepted by _ __ _ Data�/ ��- Area [. 2 op" or Grout Inspection by Dato Final Inspection by Date k 1.2a Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 IEEE AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED By DATE PERMIT-NO, l �( _' f +.EH 13-24(REV.r/nsl wV (� /a C y_,� &f 9 l�+ Q ,. EH 14-28 v