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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1YEAR 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. Job Address .City._,....d � tSize� d G.Y Q'S /' PM Owner's Name� �,1J11"t e .4d Address I�J �1 (,� , S.7LC S a/rT d C---� hone Contractor Address License 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. POOP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation ❑ Domestic/Private 1-1GravelPack Dia. of Well Casing ❑ Tracy Type of Casing Specifications ('I Public n Other p l-1 Delta Depth of Grout Seal Type of Grout _ I I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. - State Work Done Well Destruction � Well Diameter Sealing Material (top 50') ? h' Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION fI DESTRUCTION I I (No septic system permitted if public sewer is Installation will serve: Residence_ Commercial_ Other. available within 200 feet.) CJ Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg Water table depth Capacity PKG. TREATMENT PLT. El No. Compartments Method of Disposal Distance to nearest: Well foundation Property Line LEACHING LINE ❑ No. & Length of lines FILTER BED ElDistance to nearest: Well Total length/size Foundation Property Line SEEPAGE PITS I I Depth Size SUMPS — Number Ll, Distance to nearest: Well Foundation DISPOSAL PONDS ❑ Property Line 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 must call for all required inspections. Complete drawing on reverse side. Signed X Title: Date: - / 2 *-. 2 7 FOR DEPARTMENT U E ONLY Application Accepted by Date Area 7 Pit or Grout Inspection by Dat Final Inspection by `5 7 y ate Additional Comments: _ ❑ Stk466-6781 ❑ Lodi 369 3621 ❑ Man ca 82319 -7104 ❑'Tracy 835 6385 �`�`�'� `! `✓ Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 q17 FEE AMOUNT DUE AMOUNT REMITTED INFO CASH RECEIVED BY DATE PERMIT•NO. r EH 1324 IREV.t/HSi _ EH 14-2d _