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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 'I'YEAR FROM DATE ISSUED (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. IB62 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Jab Address �' jCity Lot Size PM Owner's Name &fq=gV �� k Address E �7 ��d "" PhoC 3 a/� Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHE DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 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 Cl Tracy Type of Casing Specifications FI Public Cl Other F Delta Depth of Grout Seal Type of Grout---_ I I Irrigation —..Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material )top 50'i Depth Filler Material IBelow 50'1 — \LI EPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.) on will serve: Residence— Commercial_ Other of living units: Number of bedrooms r of soil to a depth of 3 feet: Water table depth K ❑ Type/Mfg Capacity No. Compartments I l A ENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LINE ❑ No. & Length of lines Total length/size D ❑ Distance to nearest: Well Foundation Property Line SEEPAGEPITS \Depth Size _ Number SUMPS istance 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 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, 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 California." The applican ust call for all required inspections. Complete drawing on reverse side. Signed X Title: _ Date: FOR DEPARTMENT USE ONLY Application Accepted by Date v Area Pit or Grout Inspection by Date Fina! Inspection by� Date ' d Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 © Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2005, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO EH 13-24(REV.1ik5) i 1' EH 14-26 1 �� + -