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APPLICATION FOR PERMIT x SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 11-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. " i Job Address . Cit i le y Lot Size PM Owner's Nam r Address Phone e J-CIf ��Contractor Address License No._ Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ l 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 ❑ Manteca Dia. of Well Excavation Dia. of Well'Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Cl PublicSpecifications ❑ Other fl Delta Depth of Grout Seal I I Irrigation f- Type of Grout t7 Approx. Depth i I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done e �e Y Well Destruction ❑ Well Diameter Sealing Material (top 50'j e- Depth I Filler Material {Below 50') fe. TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION l 1 DESTRUCTION i 1 (No septic system permitted if public sewer is ! f available within 200 feet.) 1 Installation will serve: Residence� Commercial_ Other Number of living units: Number of bedrooms r Character of soil to a depth of 3 feet- SEPTIC TANK ❑ Type/Mfg; Ca acit PKG. TREATMENT PLT. ❑ a P Y No, Compartments :k Method of Disposal l\ Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines ---�,. - Total length/size FILTER BED ❑ Distance to nearest: Well— Foundation Property Line SEEPAGE PITS l I Depth "'� Size Number SUMPS ❑ Distance to nearest:- -r Well Foundation Property Line DISPOSAL PONDS ❑ 11 . . 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." Contractors hiring or sub-contracting signature certifies the following: "I certify that in the performance of the woik 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 onreverseside. WSigned X lLe� Title: �� Ad�_ * r Date: FOR DEPARTMENT USE ONLY' Application Accepted by Date r�2 y V rea A Pit or Grout Inspectio b Date Final Inspection by r�7 Date Additional Comments:' ❑ Stk 466-6781 ❑ Lodi 369,36211 ❑ 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 INFO FEE AMOUNT DUE 1 AMOUNT REMITTED K C H RECEIVED BY DATE PERMIT*NO. EH 14-28 3 JK EH 13-241REV.:iH5) ��