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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 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. n ` Job Address Z_ t .— City Lot Size PM Owner's Name Address Phone c r' �, Contractor ,c�Y� 4�. Address d ` License No.�9'4k Phone .. / TYPE OF 6-6 WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION L/I 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/P ❑ Open Bottom ❑ Manteca Dia. of We" Excavation Domestic/ ❑ Gravel Pack ❑ Tracy Dia. of Well Casing F\ Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal ❑ Irrigation ---Approx. of Grout i pprox. Depth L1 Eastern ,Surface Seal installed by Repair Work Done ❑ Type of Pump _a4_ - H P Well Destruction ❑ Well DiameterState Work Done Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is , Installation will serve: Residence * available within 200 feet.) Commercial_ Other- Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK ❑ T Water table depth Type/Mfg Capacity PKG. TREATMENT PLT. No. Compartments Ll --�-�--- --�-�-• Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines FILTER BED Total length/size ❑ Distance to nearest: Well ' Foundation• Property Line SEEPAGE PITS ❑ Depth Size SUMPS Number ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ElI 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 performa-Me 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 must call for all required inspections. Complete drawing on reverse side. Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Pit or Grout inspection by Date Final Inspection by Date 1�% LX> Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 0 Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK INFO CASH RECEIVED BY DATE PERMIT'NO. + EH 13-24 iREV.1,w sr 0� EH 1428 — y fc]