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APPLICATION FOR PERMIT 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. r— Job Address v C\vim City Lot Size PM Owner's Name�O� ` _ �1 1 Address - Phone Contrac Address � v�( License No.`- \ l�Phone" TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ • / �� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC TIO ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing OL ❑ Domestic/Private IXGravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. _ State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') _ Depth Filler Material (Below 50') \ ` TYPE OF SEPI C WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION F' (No septic system permitted if public sewer is__ �N available within 200 feet.) v Installs ill serve: Residence_ Commercial___ Other Number of living Number of bedrooms Character of soil to a dept feet: ater table depth SEPTIC TANK ❑ Type/M g Ca No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Foundation Property Line LEACHING LINE ❑ Length of lines Total length/size FILTER BED EJDistance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation_ Property Line DISPOSAL PONDS Cl 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 emplo any person in su manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifi a following: "I rt.fy that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion la o California." The appli t ust call for II required i pe tions. Complete drawing on reverse side. _ Signed .r1 Title: Date: _ l/z F T T N�1( f Application Accepted by Date — j�rArea Pit or Grout Inspe on Date Final Inspection by K Date Z- Additional Comhrtfints: ❑ Stk ;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 FEE INFO AMOUNT DUE AMOUNT REMITTED H RECEIVED BY DATE PERMIT NO. EH 428 1EH;3-24(REV,lie Si 3S _✓ 3S ` / �—/ �� —\, +-SPO