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�r--• APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 jPERMIT 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/of 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. f ! - A �j (�� ► City of ' Job Address Size PM�--=— 9 Owner's 'Name> gyres$ Phone Contractor Address License No. Phone_ TYPE OF WELL/PUMP: NEW 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 PITSISUMPS 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 ❑ Tracy Type of Casing Specifications — Q Irl Public ❑ Other + FI Delta Depth of Grout Seal Type of Grout ►/1 I I Irrigation --Approx. Depth I 1 Eastern Surface Seal Installed by - 4 , Repair Work Done E1 Type of Pump 'H.P. State Work Done _ 'v Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') — TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION I I DESTRUCTION I 1 (No septic system permitted if public sewer is n� available within 200 feet.) Installation will serve: Residence_ Commercial— Other E Number of living units: Number of bedrooms E Character of soil to a depth of 3 feet: Water table depth f SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line t LEACHING LINE D No. & Length of lines Total length/size ' FILTER BED ❑ Distance to nearest: Well Foundation Property Line i SEEPAGE PITS l I Depth Size Number SUMPS 0 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, and k rules and regulations of the San Joaquin Local Health Di1trict. 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."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- tion laws of California." 11 ' The applicant ust call for all req 'red inspections. Complete drawing on reverse side. c � Signed X tie: Date: FOR DEPARTMENT USE ONLY 71 Application Accepted by Date `�� Area Pit or Grout Inspection by Date Final Inspection by `AJ e Additional Comments: ❑ Stk 466-6781 ❑ Lodi 36-3621 ❑ Manteca 823-71IN ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95241 FEE AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT'No. I INFO a.EN 1344IREV.1/H51 ,2,+6`1 EH 14-2e