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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. l of /� Job Address � r City � � Size PM_� Owner's Name ;CEA:4 Address Phone Contractor Address f License No. hone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR U OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK - SEWER LINES DISPOSAL FLA. 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 Public L1 Other F1 Delta Depth of Grout Seal Type of Grout --- I I irrigation Approx. Depth l i Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealirig Material(top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 'REPAIR/ADDITION DESTRUCTION l t INo septic system permitted if public sewer is ,// available within 200,feet.) Installation will serve: Residence + Commercial_ Other ---Num#�er-of-living-units: � Number-of-bedrooms—�=.�----------�------f"' —--� . - -- —------.— - Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENTPLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line psi— LEAPHING LINE No. & Length of lines F _ - Total length/size ".FILTER BED ❑ Distance to nearest: Well' Foundation T Property Line SEEPAGE PITS I l Dep'th Size_Y.— Number SUMPS ❑ Distance to nearest: Well 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 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 a certifies the foilowing: "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 Catifornia." The applicant must call for *required inspectiQ_rs:;Complete drawing on reverse 'side. Signed K 4Z Title: Date:FOR DEPARTMENT_USE ONLY Application Accepted by Date + Area �J�p Pit or Grout Inspection by Date Ff6il inspection by Date Additional Comments: ❑ Silk 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 IFEE NFO AMOUNT DUE. .', AMOUNT REMITTED r CASH RECEIVED BY DATE PERMIT NO. OF +.EH13-241REV.i/nsl // d '- r EH 14-28