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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED k (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. likJob Address City of Size PM Owner's Name Address Xk,4, 4one Contractor Address 4"license No. Phon7 — 4 TYPE OF WELL/PUMP: NEW WELL WELL REPL CEMENDI DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAI OTHER ❑ • DISTANCE TO NEAREST: SEPTIC TANK EWER LINES �� ,DISPOSAL FLD.__ ROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS .❑ 1 strias ❑ Open Bottom ❑ Manteca Dia. of Well Excavatibn Dia. of Well Casing omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public C1 Other 11 Delta Depth of Grout Seal Type of Grout rigaUon --.Approx. De h I I Eastern fSurface Seal Installed y Repair Work Done 0 Type of Pump . H.P. �::17 State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other i 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 FJ Distance to nearest: Well_ FaVdation Property Line SEEPAGE PITS I _Depth Size Numbs/-"'�.. SUMPS L1 Distance to nearest: Well Foundation 'Property Line { DISPOSAL PONDS ❑ (i I hereby certify that I have prepared this application and that the work wilt be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the„San Joaquin Local Health MItrict. r , Home owner or licenselagent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not r( � employ any person in such manner as to become subject to workman's compensation taws of California.” Contractor's hiring or sub-contracting s gnature Lar' certifies the following: 'A 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 applicant To call for II req r ins etions. Complete drawing 7o Jerse Signed X Title: Date: 6/7 FOR DEPARTMENT USE ONLY Application Accepted"by pate �� Area Pit or Grout Inspection by Date Final Inspection-by- Date C Additional Comments; ❑ Stk 466-6781 0 Lodi 369-3621 0 Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE -AMOUNT-REMITTED.. CKN CASH "RECEIVED BY DATE PERMI7'NO. � •.EH 13-24 1REV.1/N 51 (� F�-� —OL EN 14-29 lys F— �L V o ''ti]�.?