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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE LTON AVE., STOCKTON, CA Telephone (209) 466-6781 l 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 F .Local Health District. 4 /C/r;%i1t"c City,� �'3 Lot Size' � PM Job Address �,:• .4 .. r i' . , ._ :4r, * �{l3f! , mr .. Owner's Name.�' ��r`-� � Address " Phone. W Contractor a Address License Phone TYPE OF WELL/PUMP: N W WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ f� o PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ V� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE rn I 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 ' El Domestic/Private ElGravel Pack ❑ Tracy Type of Casing Specifications epth of Grout Seal Type of Grout ❑ Public ❑ Other ❑ Delta D ❑ Irrigation ---Approx. Depth ❑ Eastern �„Surface Seal Installed by i Repair Work Done C2 Type of Pump ',H:P.State Work Done 1 Well Destruction ❑ Well Diameter i Sealing Material (top 50') Depth ' "'- Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION [3DESTRUCTION ❑ (No septic system permitted if public sewer is 4 J available within 200 feet.) Installation will serve: Residence, Commerclal_ Other Number of living units: Number of bedrooms .:Y ' el Character of soil to a depth of 3•feet: l�6 ' ' Water table depth' c3 SEPTIC TANK El Type/Mfg Capacity No. Compartments —P_KG.TREATMENT PLT.-❑ -- -� f a' Method of Disposal Distance to nearest: Well1 Foundation Property Line --LEACHING-LINE ❑-rrNo�-&=L-ength-of-lines —�� o Total length/size i / , FILTER BED El Distance to nearest: Well��, Foundation /r7 Property Line_.46Q — SEEPAGE PITS ❑ Depth'1 '=” Siie A CDO Number SUMPS ❑ Distance to nearest: Foundation Property Line { DISPOSAL PONDS ❑ I `r ` 1. 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 hiN 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."Contractors 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 i tion laws of Califor I _ The applicant st all f all required inspections. Complete drawing on reverse side. Signed Title: � Date: FOR DEPART USE ONLY / CQ . .;; f± � Application Accepted by Date I Inspection b Pit or Grout Inspection by ate Fina p y Additional Cornmerits: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permif/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ' FEE " AMOUNT DUE-' ✓ AMOUNT REMITTED. CASH RECEIVED BY DATE, ;PEREMIT .)NFO 4 r5.q + EH 13-24(REV.t/S 5) EH 14-26 t -