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n APPLICATION,FOR PEJRMIT 0 , R. - 0 SAN JOAO.UIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.,,;STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1 ,; .(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 I 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 ► v �✓ ' City wl t Size PM Owner's Nam " Address — t � i Phone t •--� r " Contractor ' Address License iN Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR K OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES- DISPOSAL FLD. PROP. LINE ti k 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 OL Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 'E ❑ Public ❑ Other [ ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx.°Depth LJ Eastern urface Seal installed by f Repair Work Done 3r Type of Pump H.P. State Work'Done C f 4. Well Destruction ❑ Well Diameter X Sealing Material )top 501 r i Depth * €9,Filler-Material {Below 50'1 E p TYPE OF SEPTIC WORK: NEW INSTALLATION-O"'REPAIR'/•ADDITION"'❑T"DESTRUCTION El-(No§eptic system permitted if public sewer is available within 200 feet.) A' f Installation will serve: Residence Commercial;�_Other � {f � F i Number of living units: -Number of bedrooms t 'S Character of soil to a depth of,3 feet. ; t Water table depth si rI R Capacity ��* N SEPTIC TANK ❑ T}pe/Mfg o. Compartments } . J PKG, TREATMENT PLT. ❑, � Method of Disposal I n Distance to nearest: Well"�� Foundatio -' Property Line 4 LEACHING LINE ❑ No.'& Length of lines r, ` Total length/size I FILTER BED ❑ Distance to nearest: Well Foundations N PropertyLine ilii Distance —, i SEEPAGE PITS ❑ Depth Size Number SUMPS ❑.. Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby Y certif that I have prepared this'application and that the work will be done in accordance with San Joaquin cou-1V ordinances, state laws, and rules and regulations of the San Joaquid 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 ibecome 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 workma 's com nsa- tion laws of California.". The appli st call for all r ui in ions. C mplete drawing on averse side. Signed Title: v� Date: Y Application Accepted by FOR DEPARTMENT USE ONLY --� Date Area O r Pit or Grout Inspection by # Date Final Inspection by Date Q Additional Comments: 7 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 111 Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT NO. �- CAS + EH 13-24[REV.1i95) 3S 1 EH 1428 ..