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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE I ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is'.hoteby 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. y(.Job Address .Q City Lot Size ply) // �i9L�C�` C wner's Nam / dress _ Phone Contractor Address License No. Phone t TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i! PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ` DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 1i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial i i.. ❑ Open Bottom ❑ Manteca Dia. of Well ExcavationV Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public C1 Other F1 Delta Depth of Grout Seal Type of Grout I I Irrigation Approxi Depth I 1.Eastern Surface Seal Installed by Repair Work Done C7 Type of Pump H.P. State Work pone_ Well Destruction ❑ Well Diameter Sealing Material [top 50') Depth Filler Material (Below 50') l v TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION (No septic system permitted it public sewer is t available within 200 feet.) Installation will serve: Residence_t Commercial— Other- n Number of living units: Number of bedrooms ,i Character of,soil to a depth of 3 feet: I Water table depth SEPTIC TANK] ❑ Type/Mfg I Capacity No. Compartments r PKG. TREATMENT PLT. ❑ t I Method of Disposal r Distance to nearest: Well Foundation Property.Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED I ❑ _Distance to nearest: Well Foundation Property Line 1< SEEPAGE PITS I 1 Depth Size Number SUMPS 0 Distance to nearest: Well (Foundation Property Line 5 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. 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 ormance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." Thea t mus c I r all qui din c ons. Compl yawing on reverse side. rt �+ Signe X i L Title: G Date: s ti FOR DEPARTMENT USE ONLY Application Accepted by Q Date � r✓ Area Pit or Grout Inspection by Date Final Inspection by ,; ��, ■ � Date Additional Comments: El- 0 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca E23-7104 ❑ Tracy 835-6385 PA- Applicant- Retu'r'n all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED IN AS RECEIVED BY DATE PERMIT'NO. +.EH 124IAEV.riH EH 14-4- SY 26 -'