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APPLICATION >=0R PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 ` PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Pep. (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.Ahli' application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for welUpump and the Rules and Regulations of the San Joaquin Local Health District. ^� Job Address City Cot Size PM Owner's Name i / Address Phone Contractor :iQ,/!"LAddress ..lam �d°e License No.,32AQz/6 Phone &` rldi TYPE OF WELL/PUMP: NEW WELL. ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ DISTANCE TO !NEAREST: SEPTIC TANK . SEWER LINES DISPOSAL FLD. PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS _ INTENDED USE TYPE OF WELL PROBLEM;AREA CONSTRUCTION-SRECI;FICATIONS ❑ Industrial D Open Bottom ❑ Manteca Dia. of Well Excavation — ` Dia. of Well Casing ` Domestic/Private EI Gravel Pack ❑ Tracy Type of Casing Specifications Fl Public Cl Other n Delta Depth of Grout Seal Type of Grout _ I I Irrigation 1,_Approx. Depth /rI I Eastern Surface Seal Installed by Repair Work Done to Type of Pump H.P. Z State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material {Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION 1.1 DESTRUCTION I I (No septic system permitted if public sewer is available within 2.00 feet.) Installation will serve: Residence _ Commercial_ Other r Number of Erving units: Number of bedrooms i. Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg $ Capacity No. Compartments L /� PKG. TREATMENT PLT. ❑ Methodof.Disposal w) Distance to nearest: Well Foundation' '_ Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth { � "Size -- -- - Number r" SUMPS ❑ Distance to nearest:—"' Well _ } Foundafion t Property Line f DISPOSAL PONDS ❑ 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 Di%trict. 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 i 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 Cal' nia." r The ap ant mu call for all requ' inspecti Com ete drawing on reverse side. Signed XTitle: Date: OR DEPARTMENT USE ONLY i Application Accepted by !10Date Area r i Pit or Grout Inspection by Date Final Inspection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 J ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. LSI r y +.EH13-21tREV.tiHsr 3,5-oo LO-941 9-101-1-9-101-1-365—, 5 EH 14-2$ I y