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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i ON AVE., STOCKTON, CA ! 'F Telephone (209)466-6781 PERMIT EXPIRES 1 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.1051 for well/pump and the Rules and Regulations of the San Joaquin Local Health District.A7j `/CJ CMCJ Job Address CityS4 Lot Size 21. PM Owner's Name _ Address 5 Contractor ddress License No. 1 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ 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 ❑ Domestic/Private CI Gravel Pack ❑ Tracy Type of Casing Specifications C Ll'7' ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation —4pprox. Depth ❑ Eastern Surface Seal installed by Repair Work Done ❑ Type of Pump H.P. State Work Done I Well Destruction ❑ Well Diameter Searing Materia! (top 501 I Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW 1NSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is f� available within 200 feet.) Installation will serve: Residence_ Commercial_ Other ('Number of living units: Number of be ooms I Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 171Type/Mfg Capacity No. Compartments 1 'PKP,. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well d Foundation 12—_ Property Line it F LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Wel{ 190 Foundation 3_0 Property Line 2 S— SEEPAGE PITS ❑ Depth 2 ' Size Number SUMPS . ❑ 11isfarice to nearest: Wellf�U Foundation K_ Property Line DISPOSAL PONDS O I he certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and I rules and regulations of the San Joaquin Local Health District. r Home owner..or licen.so agent's signature certifies the following: "I certify that in the performance of the work for which this perrnit 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 pemlit is issued,I shall employ.persons subject to workman's Fcompensa- tion laws of California." The applicant us`call for required inspections. Complete dwa�ving on reverse side. Signed Title: _ * Date: 1 FOR DEPARTMENT USE ONLY F Application Accepted by ` Date ff�� —/}�/�J Area �t�or Grout Inspection by Dat ��i Final Inspection Wlfl �' D�� Additional Comments: ❑ Stk 41ro-M1 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑Tracy 1335-6315 Applicant- Return all copies to: Environmental Health Permit/Services 1501 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH EH 13-24(REVV.1/8 5) EH 14-26 7�