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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRkT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 1209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED A (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. Job Address o _ 6Z City��„(!.rz� Lot Size Y PM Owner's Name r Address cam:–�r�p; gc-I�l� Phone Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ j PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISP FLD.__ PROP. LINE FOUNDATION ICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA UCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. o ell Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ T Type of Cast Specifications ❑ Public ❑ Other Delta Depth of Grout Seal Type of Grout O Irrigation _Approx epth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of ump H.P. State Work Done _ Well Destruction ❑ 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 fee Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line t LEACHING LINE ❑ No. & Length o s Total length/size FILTER BED ❑ Distanc nearest: Well Foundation Property Line SEEPAGE PITS Depth Size Number SUMPS ❑ .Distance to nearest: Well Foundation Property Line �I DISPOSAL PONDS C7 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 IE for required ins io Complete drawing on reverse side. Signed X Date: FOR DEPARTMENT USE ONLY ^� Application Accepted b Date G ' Area d 3 Pit or Grout Inspection by Date Final Inspection byDate Additional Comments: ❑ Stk 4666781 0 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83546385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE pp INFO AMOUNT DUE AMOUNT REMITTED CK* RECEIVED BY DATE PERMIT'NO. -24(REV EH 1428 + EH 14 .1/85) C11:1 f