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APPLICATION FOR PERMIT .-•" SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Ns�� Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED 1 (Complete in Triplicate) 1 CQES` Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This applicat�rt SO:, made in compliance with San Joaquin Coun Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health Dis Job Address 9.IV �+ City Size PM Owner's Name Address C �i�CJ Phone Contrac ass .6.1 _ License No��Phone I / ( 7 O TYPE OF WELL/PUMP: 9NEW WELL ❑ _WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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 ❑ Domestic/Private ❑ Gravel Pack 171Tracy Type of Casing Specifications 1`1 Public ❑ Other f 1 Delta Depth of Grout Seal Type of,Grout, Q� 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 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION LI DESTRUCTION 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 fi SEPTIC TANK ❑ Type/Mfg ' Capacity No. Compartments 4 PKG. TREATMENT PLT- ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance tc nearest: -• Well Foundation Property Line SEEPAGE PITS r .1 1 Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1r 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 cal fo ns. Complete drawing on averse side. Q� Signed X Title: Date: U FOR DEPARTMENT USE ONLY 1(� Application Accepted by Date ' y` Area • Pit or Grout Inspection by Date Final Inspection by LL 2 Date Additional Comments: 07 (.,/4 � / 4 _ s-� s . 99Z S � c� ❑ Stk 466-6781 ❑ Lodi 369- 621 ❑ 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 FEEMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO, INFO 1 + EH 13-241REV.1/"5) �5!? `_1 FH 14.26 ` r