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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 (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. Job Address gz �D / of Size P'Me�'(f' G Owner's Name Phone Contractoricense N� one TYPE OF WELL/PUMP: NEW EL WELL REPLACEMENT ❑ DESTR TION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. 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 f"1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout 1 I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') C Depth Filler Material (Below 501 C TYPE OF SEPTIC WORK: NEW INSTALLATION IK REPAIR/ADDITION ( I DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Res' nce-t— Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 0Type/Mt9 Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal !— Distance to nearest: Well�._ Foundation Property Line _J U LEACHING LINE ❑ No. & Length of lines �— Total length/size —jylq! el FILTER BED ❑ Distance to neareSF. Well� FoundationProperty Line lSU SEEPAGE PITS I I Depttt E _•,� _ Number— L1 umber_Ll Distance .o nearest: We' _EDundation _ rProperty Line_ DISPOSAL PONDS ❑ 1 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 D3trict. 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 applicant al squire in cions. Complete awing on reverse side. Signed X ,/// Title: Date: FOR DEPARTI/4)f,ENT USE ONLY Application Accepted by�� 5C� L_ Date � r�U Area Pit or Grout Inspection by �y-�,iy/Date Final Inspection by / � il�-1 Date Additional Comments. `7 ❑ Sik 466-6781 ❑ Lodi 369-362 tete 823-704 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. . EH 13.24IREV.iinS, EH Ilex 1 Vfg qO 1