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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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. / ,J° Job Address fJ /1� � I o City C iLot Size ' PM Owner's NameC�<��'r .�'/��7/�/�/� Address Phone Contractor AddressA License No. / _Phone.5P� k TYPE OF WELL/PUMP: NEW WELL V WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATIONV SYSTEM REPAIR ❑ OTHER LI DISTANCE TO NEAREST: SEPTIC TANK042,' 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 El Tracy Type of Casing " Specifications Public ❑ Other ❑ Delta Depth of Grout Seal T�re of Grout I I Irrigation Approx. Depth ❑ Eastern ,race Seal Installed by Repair Work Done Ll Type of Pump w1 H.P. � State Work Done _ Well Destruction f-I Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ 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. [ I Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth _ _Size Number SUMPS ❑ Distance to nearest: Well __ — Foundation Property Line DISPOSAL PONDS 17 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 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 a I required inspections. Complete drawing on reverse side. ^�r Signed X_._,e!!�22[, Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by L1. Date Area /a Pit orrou3 Inspection by ate Final Inspection by Date 1 �'—Sf 7 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 95201 FEE CK INFO AMOUNT DUE AMOUNT REMITTED 67Ei RECEIVED BY DATE X_/ 7 + EEH 3-24 H 14-26 SH (REV. ` �.