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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT w_ 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 I PERMIT EXPIRES TYEAR 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. 3o ►4 Cit � �^J Lot Size 0 PM J��AddressY J� Owner's Name /7�>~/►'rC!/7 /f/�fY1 Address JO �' ��^��. Phone �" 2 i r r ! � Contractor]i� / t —Address- License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑- - WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION'M - 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 C� ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications V� M Public ❑ Other 1 ❑ Delta Depth of Grout Seal Type of Grout ._. � I I Irrigation _-.Approxi 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') Depth Filler Material (Belowf50') TYPE OF SEPTIC WORK: NEW INSTALLATION 11, REPAIR IADDITION'1'I,- DESTRUCTION (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 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 r r FILTER BED ❑ Distance to nearest: 'Well Foundation Property Line SEEPAGE PITS f I Depth I Size Number SUMPS ❑ Distance,to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that I have prepared thi's 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 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 must call for all required ins ec.tions. Complete drawing on reverse side. E Signed X ` Title: Date: q 3 Air FOR DEPARTMENT USE ONLY %} Application Accepted by t Date Area c-/ p Pit or Grout Inspection by I Date Final Inspection by �_�1,� Date �399 0 Additional Comments; ��l I aas S y _ .2"Sky�. Stk 466-6781 ❑ Lodi -3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Al;bficant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 20M, Stk., CA 95201 n FEE INFO AMOUNT DUE AMOUNT REMITTED OK RECEIVED BY DATE PERMITNO. ' + EH13.24 IREV,1/N 57 EH 1t-2t1