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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA � k" w G Telephone (209) 466-6781 f PERMIT EXPIRES 1 YEAR FROM DATE ISSUED w- (Complete in Triplicate) Application is hefeby 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 'u '0 ity �' Lot Size ��~ PM Owner's Name_ �Ad� Phone Contractor �i �T ,� �_ (Zz Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIROTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES rISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ 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 (� Public n Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation _.,Approx, Depth I 1 Eastern Surface Seal Installed by _ 1 Repair Work Done ❑ Type of Pump H,P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50') Depth Filler Material (Below 501 9 TYP F SEPTIC WORK: NEW INSTALLATION {'I REPAIR/ADDITION f I DESTRUCTION I 1 {No septic system permitted if public sewer is S available within 200 feet.) Installation erne: Residence_ Commercial_ Other Number of living u Number of bedrooms �� Character of soil to a dept 3 feet: Water eWe' epth SEPTIC TANK ❑ Type Capacity o. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest- Foundation Property Line LEACHING ❑ No. & Length of lines Total length/size FILTER B LJDistance to nearest: Well Fo tion Property Line SEEPAGE PITS 11 Depth Size bar SUMPS Ll Distance to nearest: Well Foundation Line DISPOSAL PONDS L I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin cou 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 ap ' ant ust call for ail required in fo Complete drawing on re side. Signed Title: . __-- Date: FOR DEPARTMENT USE ONLY o ication Accepted by Date 2 �,�� Area Pit of Grout Inspection b bate Final Inspection by Date t/ 01,we, Lv-al 15-II flvoav- -fr 19vfir-/SII'. It- Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., Box 2009, Stk., CA 95201 INFO AMOUNTDUEAMOUNT REMITTED CK H RECEIVED BY DATE jPPET'NEH}3-24{flEV.r/n 51 3` - EH 14-2t} V