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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 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 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. IM Job Address I ` City Lot Size PM Owner's Name ^i Address '�� _. Phone if Contractori ,.= t 14 h~ Address ` lvicense No, Phon;3 �r 7 TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ b DISTA"NCE.TO NEAREST: SEPTIC TANK ! SEWER LINES DISPOSAL FLD. PROP. LIN�6Ohh , IM FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS/ INTENDED TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ElOpenOpen Bottom Manteca Dia. of Well Excavation Dia. of Well Casing �I" ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f"i'Public f) Other n Delta Depth of Grout Seal Type of Grout I I Irrigation I —.-Approx. Depth i I Eastern Surface Seal fnstalled by Repair Work Dome 0 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') sP" Depth - — - - Filler Material {Below 50') TYPE OF will SEPTI`C WORK: NEW INSTALLATION i"I REPAIR/ADDITION l I DESTRUCTION I 1 (No septic system permitted if public sewer is Installation I1: available within 200 feet.] serve: Residence_ Commercial— Other Numberlof living units: Number of bedrooms V Character of sail to-a-depth of 3 feet: Water table depth 1 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG.'TREATMENT PLT. ❑' Method of Disposal l Distance to nearest: Well Foundation Prooerty.Line LEACHING LINE " ❑ No. & Length of lines Total length/size FILTER BED i ❑ Distance to nearest: Well Foundation Property Line I SEEPAGE PITS" I 1 Depth Size Number SUMPS j D Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 11 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, sI rules and regulations of the San Joaquin Local Health District. tate laws, and Homeowner 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." 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 workman's compensa- tion laws of Califgrnia." ' The applicant ust call for all required 'n�pections. Complete drawing on reverse side. Signed v Title: - 1p f Date: Q FOR"DEPARTMENT USE ONLY" J w Application Accepted by Date Area b Pit or Grout Inspection by Date— Inspection by 1t I Date :r Additional Comments: ❑ Silk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 Applicant Return all copies to: Environments! Health Permit/.Services 1601 E. Hezeltori Ave., P.O: Box 2009, Sik.,.CA 95201 • FEE R i INFi3 AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE E1�3N;] t +.Eli 13-21 IREV.r/a5) ' (" EH,14-2e ca