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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 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. Job Address { City � �� Lot Size PM Owner's Name ddress �S� /►`l/IC �L Phone �'U �•�Il/ Contractor. ;i Address License No. hone_ TYPE OF WELL/PUMP:(/ NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUC N PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ O HER ❑ DISTANCE 70 NEAREST: SEPTIC.TANK SEWER LINES DISPOSAL FLO. PROP. LINE C FOVNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS l INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS D Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia: of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy_ Type of Casing Specifications ❑ Public ❑ Other ` ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation _--Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ n Well Destruction ❑ Well DiameterSealing Material {top 501 v Depth Filler Material {Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION ElREPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet,I ntaf}ati wdl serve: Residence Commercial Other Number of living u Numbelr of bedrooms Character of soil to a depth of 3 fee . Water table depth i SEPTIC TANK ❑ Type/Mf 9 Capacity Na. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal Distance to!nearest: Well Foundation Property Line i f LEACHING LINE ❑ No. & Length of lines Total length/size j FILTER BED El Distance to',nearest: Well Foundation Property Line II SEEPAGE PITS ❑ Depth l} - Size Number SUMPS ❑ Distance to,nearesV Well Foundation Property Line DISPOSAL PONDS ❑ - if i 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, 1 shall not employ any person in such manner as Jo become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify thaYin the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." c The applicant must calls for all requii jre in,pections. Complete drawing on reverse side. L�7 Signed X C��`"-+�a' t Title: Date: 'I FORPEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout inspection by it Date Final Inspection by 2 Date y r�_ Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-36211 ❑ Manteca 823-7104 ❑ Tracy Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO yC�ASH { L..� �r (\ 13-211REV.iiHsl [�✓ �r� �� A �i f�� i � l ' 10-19 14.28 J D