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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) CC 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 City�_— Lot Size PM /� S Owner's Name Address Phone 'Contractor Address 1 License No2]j/ff - Phone ,TYPE OF WELL/PUMP: NEW WELL G WELL REPLACEMENT ❑ DESTRUCTION Ci PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. _ ROP. LINE FOUNDATION AGRICULTURE WELL' .OT L 4PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONS ON SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca w. of Well Excavation _ Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack C Type of Casing Specifications - ['I Public 1-1 Other 17 Delta Depth of Grout Seal Type of Grout 11 Irrigation pprox. Depth l I Eastern Surface Seal Installod by _ - Repair Work Don Type of Pump _— H.P. State Work.Done Well Des ion ❑ Well Diameter Sealing Material (top 50'} - Depth Filler Material (Below 50") - TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION/N (No septic system permitted if.puhlic 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 o1 3 feet: Water table depth _ SEPTIC TANK ❑ Type/Mfg _ Capacity No. Compartments _ PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line— LEACHING LINE fl No. & Length of lines ___ Total length/size. . FILTER BED 11 Distance to nearest: Well Foundation Property Line i SEEPAGE PITS 11 Depth ___ Size Number SUMPS L! Distance to nearest: Well Foundation Property Line _ DISPOSAL PONDS C 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, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or subcontracting signature corti6es the following: "I cortify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa tion Iaws of California." The applicant must call fo it r quir inspections. Complete drawing on reverse side. ^ igned X _-- Title: Date� FN OR DEPARTMEN�USE NLYApplication Accepted by i�it.MDate Pit or Grout Inspection b __ Date Final Inspection by Additional Comments: `-'y"-' ❑ Stk 466781 El Lodi 3693621 ❑ Manteca 7104 ❑ Tracy 835-6385 ,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 RECEIVED 13Y DATE PERMIT-NO. INFO EH 13-24(REV,I/n 51 V U �.7 EH 14-2e