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APPLICATION FOR PERMIT '"SAN JOAQUIN LOCAL HEALTH DISTITItT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED FILE COPY (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 �I,/, f ea�so� �P /a City j—Dd4, Lot Size PM Owner's Name Address O / eA✓SDK Phone _��2 ContractoZ��rs ress�© ��I License No. 3 Phone V6 6 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT [ADESTRUCTION 11PUMP INSTALLATION R SYSTEM REPAIR Q—' 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 E+' ccmestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation / -__ Approx. Depth I Ea.ern Suda Seal Installed by Repair Work Done Uf' Type of Pump H.P. ' State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION 11, RTPAIR/ADDIT.ON I I DESTRUCTION 1 1 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg pacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to neares : WellZ-- Foun tion Property Line LEACHING LINE L No. & Length of lin s Total length/size FILTER BED Ll Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1 1 Depth Size Num SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS n 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 lice ant'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 p on in such m ner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies th ollowing: "I certify hat in the perfgwrnance of a ork for which this permit is issued, I shall employ persons subject to workman's compensa- tion law of Californi ." Thea licant must all requir i plate yawing on v i= Signed Title: Date: EPA ENT USE ONLY Application Accepted by Date Area Z— Pit or Grout Inspection by Dat Final Inspection by CU --_z Da� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 952011�'� FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH . EH 13-24 1REV.l i n al EH 14-26