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APPLICATION FOR PERMIT 1.. s- � t SAN JOAQUIN LOCAL.HEALTH DISTRICT � 1601 E. HAZEL T ON AVE_,STOCKTON, CA fR Telephone'(209) 466-6781 !PERMIT EXPIRES 1'YEAR.FROM DATE ISSUED_ ,.(Complete in„Triplicate) z' 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 Local Health District- Job Address S6 65 6C' O City Lot Size to r PM Owner's-Nam Address Phone _ } 4. Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ 9 WELL REPLACEMENT.❑ DESTRUCTION ❑ PUMP INSTAL ON ❑ SYSTEM-REPAIR Ops• OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DI SPO LD. PROP. LINE FOUNDATION ICULTURE WELL HER WELL PITS/SUMPS f INTENDED USE TYPE OF WELL PROBLEM ARE CON CTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca r . f Well Excavation Dia. of Well Casing f'� ❑ Domestic/Private ❑ Gravel Pack ❑ Trac/ Type o sing_ Specifications r F] Public F1 Other Delta Depth"of Gro eal C+i: Type of Grout. --�--- - t ❑ Irrigation ---Approx. ❑ Eastern Surface Seal Insta- by A". �� r Repair Work Done ❑ Type of Pd Well Destruction ❑ Well Diameter Sealing Material'Itop,.50') Depth Filler.Material!Below 50')'�a � „f TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO (No septic system permitted if public sewer is x available within 200 feet.) Installation will serve: Residence_ Commercial, Other T 1 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: ' Water table depth SEPTIC TANK Type/Mfg Capacitynooc, No. Compartments PKG. TREATMENT PLT. ❑ �. Method of Disposal ,• Distance to nearest: Well Foundation Property Line , .,LEACHING LINE r F1No. & Length of fines Tata/ length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line �.:- ` SEEPAGE PITS ' Depth D� Size ------Number - --� SUMPS ❑ Distance to nearest: Well Foundation Property Line { DISPOSAL PONDS ❑ I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and i i rules and regulations of the San Joaquin Local Health District. E; 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, 1 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 i 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." '# lican" must call for all required inspections. Complete drawing on reverse side. Signed Title: Date: FOR 'DEPARTMENT USE ONLY li IlF Application Accepted by Area 0 Data ~� Pit or Grout Inspection by Date Final Inspection by Date3 Additional Comments: G �4L1C- L �, ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104.4" { CI'Tracy 835-M5 Applicant- Return all copies to: Environmental Health Permit/Services.1601 E. Hazelton Ave., P.O. Box 2809, 5tk., A 95201 IFEE NFO AMOUNT DUE;1, AMOUNT REMITTED K RECEIVED BY DATE PERMIT'No. 00 o� f 1 41 P� f7-7 + EH 13-24{REV. -� E ' EH 14-26 ,