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` APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 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. 1$62 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address City Lot Size PM i Owner's Name Address Phone Contractors Address ,1,05-.!fi'�5, (cense No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PETS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS a ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Weli Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Cl Public ❑ Other P Delta Depth of Grout Seal Type of Grout 11 Irrigation —.-Approx. Depth I. 1 Eastern Surface Seal Installed by Repair Work Done D Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 I[ Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION {'l REPAIRIADDITION 1.1 DESTRUCTION)(INo 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 .M' •r# LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation .Property Line f' t SEEPAGE PITS t I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property iOne 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:, 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-coritracting 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 Calif - ' I I t I I The applican ust cal on . Complete drawing on reverse side. r r ,,r t y_.Signed X Title: _ _ Date FOR DEPARTMENT USE ONLY _ Application Accepted by date 'AreaJA v Pit or Grout Inspection by -Date+ Final Inspection by Date r Additional Comments: ❑ Stk 466-6781 .�, ❑ Lodi 369-3621 Manteca 1823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit IServices;1601.E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK R RECEIVED BY DATE PERMI7'NO. INFO pppyyy + EH 13-241REV.r/n51 EH 14-26 A62 63