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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA L� 7 `I ' Telephone (209) 466-6781 PERMIT EXPIRES 7 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. Job Address City L, 7` �� ^tot e Size ( PM a'- Owner' [�s Name Address _ J G. v l P Phone Contractor's Name M � License No. l �__�__ Phone L �- TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ O PUMP INSTALLATION DISTANCE TO NEAREST: SEPTIC TANKSEWER LINESY�b E� ROP. LINE R DISPOSAL FLD 011 ]D FOUNDATION AGRICULTURE WELL OTHER WELL<NSIVe PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑�Industrial ❑ Open Bottom C1Manteca Dia. of Well Excavation Dia. of Well Casing P Domestic/Private 4YI (travel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Typ of Grout ❑ Irrigation `D Tj Approx. Depth ❑/Eastern Surfac Seal Installed by Repair Work Done ❑ Type of Pump 5 w h H.P. t State Work Done Well Destruction ❑ Well Diameter Sealing Material )top 50'I Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— 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 Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ l 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 certifies the following:"I certify that in the performance f the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of Cal' The ant must I for all require cti Co ete drawing on reyarse side. Signed a- Title: in 0 Date: FOR D PARTMENT USE ONLY Appli tion Accepted by Date b " Area Pit or Grout Inspection by t Final Inspection by {, Date -' T1 GL 1 r 5 Additional Comments: - ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ racy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT 9UE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"NO. INFO CASH + EH 13-241REV.10/1331 EH 1428 FH—L� P