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APPLICATION FOR PERMIT - ,4 t 9 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA ' Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is he4eby 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 � Lot Size ��` �� PM Owner's Name ddress G� hone - Contractor Address License No. Phone TYPE OF WELL/PUMF1 NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ --1 DISTANCE TO NEAREST: SEPTIC SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRfGEiLTUR_E WELL OTHER WELLPITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREAS -CONSTRUCTION-.SP..ECIFICATIONS ❑ industrial ❑ Open Bottom ❑ Mant;�ca Dia. of Well Excavation Dia. of Well Casing El Domestic/Domestic/Private ❑ Gravelkr 0 Tracy Type of Casing Specifications 1-1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout-- _ Approx. Depth 1 I Eastern Surface Seal Installed by {' I I Irrigation _.App p - -r Repair Wor ne ❑ Type of Pump H,P. State Work Done _ We! struction ❑ Well Diameter Sealing)Material Itop 501) Depth Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION [:I REPAIR/ADDITION 1,1 DESTRUCTION 1 (No septic system permitted if public sewer is Q I`. available within 200 feet.) Installation will serve: Residence— Commercial_ Other!) Number of living units: Number of bedrooms iM Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. LJ Method of Disposal ` Distance to nearest: Well. - Foundation Property Line IM LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line M SEEPAGE PITS 11 Depth Size Number SUMPS D Distance to nearest: Well �`M` 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 District. Home owner or licensed agent's signature certifies the following: '9kcertify 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." Contractot's hiring or sub-contracting signature workman's com ensa- of the work for which this permit is issued, l shall employ persons subject to p certifies the following: "I certify that in the performancep P tion laws of California." 11 ' The appl' of st c II o II r ired ' ctions. Complete drawing o verse side. Signed TitlDate: FOR DEPARTMENT USE ONLY Application Accepted by I� Date h Area r Pit or Grout Inspection by Date I� Final Inspection by Date Additional Comments.�`�6 / I� ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 836-6385 V Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 j FEE AMOUNT DUE AMOUNT REMITTED,[ INFOAS RECEIVED 9Y DATE PERMIT NO. + EH 13-241i1EV.t/K5fJ i EH 1428 I cuuuJ 1