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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 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. 9 Job Address � 5 �/ t 1 City Lot Size PM j Owner's Name w Address _ � Phone Contracto 4 Address �3� icense No. 2 Phone Z$'� TYPE OF WELL/PUMP: NEW WELL © WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR Q< OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. 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 Y-Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1-1 Public Cl Other M Delta Depth of Grout Seal Type of Grout �n I I Irrigation _____Approx. Depth l I Eastern Surface Seal Installed by (nE Repair Work Done Type of Pump .4.44-_. H.P. State Work one ` „1 Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material )Below 50') — vt TYPE OF SEPTIC WORK: ,NEW INSTALLATION f 1 REPAIR/ADDITION f I DESTRUCTION I 1 (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 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Copt PKG. TREATMENT PLT, ❑ Met 4tlC�tj°Ov Met Distance to nearest: Well Foundation Property L" LEACHING LINE ❑ No. & Length of lines Total length/size juL 19 8 FILTER BED ❑ Distance to nearest: Well Foundation Property Line ENVIRONIN E rAL 1 154;EFH ^ SEEPAGE PITS I I Depth Size Number PERM ITISFRVICF SUMPS P 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 Di§trict. 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 parsons subject to workman's compensa- tion laws of California." The applican t II for all req fired inspections. Complete drawing on reverse side. Signed X Title: Date: —L`g F R EPARTMENT USE ONLY �" Application Accepted by Date ` `fli Area Pit or Grout Inspection by Date Final Inspection by ate x r� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 17 Manteca 823-7104 ❑ Tracy 635-6365 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO } CASH q + EH 13.24(REV.1/N 51 3�-�V r 7_:;11� �'73)d` EH 14-28 ✓1