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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 i (Complete in Triplicate) Application is he+eby 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 ef- Job Address ! L / / ( � City �{ Lot Size PM GJOwner's Name L, G � Address Phone Contractor LTJ±N L._ Address 'Z5D LQ icense No.4413 Phone 1 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION"-❑ SYSTEM REPAIR Cl OTHER ❑ F DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO, 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 . -Ll Domestic/Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public Cl Other ' ❑ Delta Depth of Grout Seal Type.of Grout ._ i I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by _ {L Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 1 I DESTRUCTION ptic system permitted if public sewer is � available within 200 feet.] Installation will serve: Residence� -Commercial_ Other Number of living units: Number of bedrooms i Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well 'Foundation ' Property Line LEACHING LINE LI No. & Length of-lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS ❑ Distance to nearest: Well 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. 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 certi N s 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 law f California." The applican s ca f�alletedrawing on reverse side. Signe uire ins tion ComplTitle: Date: FOR DEPARTM T USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by t,r. Date r �� 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. Hazalton Ave., P.O. Box 20W, Stk., CA 95.201FEECK 40 „A INFO AMOUNT DUE AMO NT REMITTED CASH RECEIVED BY DATE PERMIT"IVO. +.EH t3-24{REV.i/A5) EH to-26 I