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APPLICATION FOR PERMIT w , SAN JOAQUIN LOCAL HEALTH DISTRICT ftp 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 1 (PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i (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 Applica CountyOrdinance No.549 for sewag ; e or No. IB62 for well/pump and the Rules and Regulations of the San Joaquin made compliance with San Joaquin Local Health District. City 64/f"tY Lot Size PM Job Address .rr ` S Phone ' -7� 7 Address Owner's Name �a . - �� 3 CLicense No. Phone Contractor Address TYPE OF WELL/PUMP: NEW WELL F1WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR EJOTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 15POSAL FLD. PROP. LINE FOUN 10N AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF ELL PROBLEM AREA C RUCTION SPECIFICATIONS Dia. of Weil Casing ❑ Industrial El Open Bottom 11 Manteca Dia. of Well Excavation Trac Type of Casing Specifications [I Domestic/Private ❑ Gfavel Pack Type of Grout — C1 Other ' _ Depth of Grout Seal -.,. f"7 Public _ ace Seal Installed by I I irrigation _..Approx.'Dep l I Eastern Surf Repair Work Done ❑ Type of Pu H.P. State Work Done Well Destruction ❑ Well eter Sealing Ma erial (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION I I DESTRUCTION Ki aivaiiabplicle system in permitted it public sewer is ; _ Installation will serve: Residence— Commercial f Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ i Method of Disposal Distance'to nearest: Well Foundation Property Line s E i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Wel Foundation Property Line 1 SEEPAGE PITS I I Depth Size Number I7� SUMPS ❑ Distance to nearest: Well 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, ander 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 i employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature M certifies the following: "(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 m st call for all required inspections. Complete drawing on reverse side. Title: Date: Signed X FOR DEPARTMENT USE ONLY l Date 1 Area Application Accepted by 12—2 ,g Pit of Grout Inspection by p Date Final Inspection by Date O Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 El Manteca 623-7104 ❑ Tracy 835-6385 w Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT NO. +.EH 53-241REV.I/nslINFQ D�' � EH 14.26