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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 [r. e 1 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. W l4 Job Address City 'Cot Size PM ? r Owner's Name Address `, ��th'4 a Phone Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION © SYSTEM REPAIR K OTHER ❑ DISTANCE TO NEAREST: SEPTIC TAN.K SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS -INTENDED-USE 4,^._'-_:"_TYPE_OF WELL---: PROBLEMAREA trCONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing s )CDamesticlF'rivate 11 Gravel Pack ❑ Tracy Type of Casing Specifications M Public + ❑ Other f] Delta Depth of Grout Seal Type of Grout I I Irrigation- __Approic.'Depth' '1 Eastern Surf ce Seal Installed by Repair Work Done �C- Type of Pump M.P. d State Work Done 9 Well Destruction ❑ Well DiameterSealing Material {top 50'1 ` ,, N Depth �4 x.Filler Material (Below 50'I TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is j11 available within 200 feet.) .; Installation will serve: Residences Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: F .- Water table depth'- SEPTIC epthSEPTIC TANK El Type/Mfgff. Capacity No. Compartments L1 ` PKG, TREATMENT PLT. 1 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No.-,& Length of lines Total length/size FILTER BED ❑ ,Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth I Size Number SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 i rules and regulations of the San'Joaquin':Local Health Diltrict. Home owner or licensed agents signature certifies the fdtlowing: "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 com ansa- tion laws of California." I f A The applic must c I for all required inspe s. C plate awing on revae e. Signed X Title: 7 „,,,,,,,_ Date: l!' OR DEPARTMENT USE ONLY Application Accepted by Date Areatj Pit or Grout inspection by Date Final Inipection byy Date L -t Additional Comments: ❑ Stk 466.6781 ❑ Lodi 369-3621 CI 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 INFO AMOUNT DUE f AMOUNT REMITTED CK ASH RECEIVED BY DATE PERMIT'NO. +.EH t3-24 IREV.1/H 51 EH 1428 f [ '