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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicatel 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 Cit Lot Size PM f —a Owner's Nam Address Phone r � �Phone Tf 0�s+ Contract Address License No, z TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ -DESTRUCTION ❑ PUMP INSTALLATION L1 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 ❑Open Bottom ❑ Manteca Dia.of Well Excavation Dia. of Well Casing C1 Domestic/Private C.1 Gravel Pack ❑Tracy : Type of Casing Specifications I.1 Pilblic Cl Other F1 Delta Depth of Grout Seal Type of Grout__. (� I I Irrigation —_Approx. Depth I 1 Eastern Surface Seal Installed by -X Repair Work Done ❑ Type of Pump H.P, State Work Done_ Weil Destruction ❑ Well Diameter Sealing Mat&ial (top 50') Depth Filler Material (Below 50'1 -- TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: -15 Number ofJtpdtaom — _ 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: Wel!7"1�"-- Foundation t Property Line rer* (, SEEPAGE PITS I I Depth Size Number SUMPS 0 Distance to nearest: Well Foundation Property trine 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 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 applicantst all for all q red spections. Complete drawing on reverse sE l LJ Signed% Title: Data- FOR DEPARTMENT USE ONLY _ Application Accepted by �'�- ___.�_. � Date ` 7 Area Pit or Grout Inspection by .Date Final Inspection b, m �"� Date�� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ENF AMOUNT OUE AMOUNT REMITTED CK RECEIVED BY DATE PERMI7'NO. CASH . EH 13-24(REV.1/n 51 k'4 pc, - •. ,- l.� l.L � eH 14-26