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APPLICATION FOR PERMIT .ry SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA 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. 1(352 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address �0 / of Size Pm b Owner's Name Phone Contractor icense N� hone / TYPE OF WELL/PUMP: NEW EL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR Cl 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 ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done R Well Destruction ❑ Well DiameterSealing Material (top 509 Depth Filler Material (Below 501 �. TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Resnce I— Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg Capacity WaWater table depthNo. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Well ! Distance to nearest: Wel _ Foundation Property Property Line )^V LEACHING LINE ❑ No. & Length of lines ,T/otal length/size FILTER BED ❑ Distance to nearest: Well , _ Foundation _�i(,�_ Property Line _U SEEPAGE PITS I I Dep1R _ Number PSS Ll Distance .o nearest: We, ,.._Foundation _ -Property Line 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 Di§trict. 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 subcontracting signature certifies the following: ")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 a at awing on reverse side. Signed X squire in ions. Com ate Title: Date: ,�, ,y^ FOR DEPART ENT USE ONLY Application Accepted by�.XX/ �d"'�IJ / � Date ,,�0�� _ Ant. Pit or Grout Inspection by r Date Final Inspection by�X A�� —pate G Additional Comments: ^ ❑ Stk 466-6'781 ❑ Lodi 359-3621 O Manteca 823-7 04 ❑ Tracy 835-5385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK III, WFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. . EH 13-24 IRIFV iinp, I D 9� ` EH It-]6 v