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APPLICATION FOR PERMIT i� 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 we11/pump and the Rules and Regulations of the San Joaquin i Local Health-District _ bob AAddres3 �Aitij - ® FS ��A�?cuv , Lot Size PM P !J U Phone Owner's Name, t 5 Address r I - � ' l k Contractor w�WF L' k Address G ` License No. -70, ___Phone 3' TYPE OF WELL/PUMP: NEW WELL J1,— WELL REPLACEMENT ❑ DESTRUCTION El PUMP'INSTALLATION F SYSTEM REPAIR ❑ OTHER D 1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION, AGRICULTURE WELL'_ OTHER WELL PITS/SUMPS I INTENDED USE TYPE OF WELL 'PROSLEIVi AREA CONSTRUCTION SPECIFICATIONS If I ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Eparnestic/Private ravel Pack ❑ Tracy Type of Casing «� Specifications r M Public Ll Other f;, fl Delta Depth of Grout Seal Q Type of Grout — I I Irrigation anal pproxi Depth J I I Eastern Surface Seal installed by i Repair Work Done ❑ Type of Pump �{d `�_ H.P. _.� - State WDone_ E Well Destruction ❑ Well Diameter rt Sealing Material (top 501 Depth�d11f1G5C��,c�,r .-Filler Material-(Below 5&I. rig TYPE OF SEPTIC WORK: NEW!INSTALLATION l 1 REPAIR/ADDITION l I DESTRUCTION l 1 INo septic system permitted if public sewer is :I 11 ,.r--„ ,,,,,,,_r_.._.-- :--..T_.-t_ available within 200 feet.) Installation will serve: Residence_tCommercial_ 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. ❑ IA " , * _# Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No &Length of tines %{ y Total length/size FILTER BED ❑ Distance to nearest: Well/ Foundation Property Line .li SEEPAGE PITS ( I Depth Size I Number' SUMPS D Distance to nearest: Well t Foundation Property Line'- DISPOSAL ine-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 li 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 -A call for all cti s. Complete drawing on r rse side. r _ � Signed Title: �� Date: ;� -'Y� i FO PARTMENT USE ONLY ' Application Accepted by Date3 � Area d - Pito Grou nspection b Ir Date/.,/ Final inspection by Date T 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 IFEENFO . MOUNT DUE AMOUNT REMITTED C .H RECEIVED BY DATE PERM17'NO. '' - + EHt3-244REV.rixsr � EH 14-26 D s O f