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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT C-15 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 it 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. Job Address Fn" City S e PM Owner's Name 1 Address Phone _� Cantracto V '�) EMI Address2L ��+License'NoU Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ r DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR'❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROB M AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom © Mante o eT Exc ation Dia. of Well Casing 'r ❑ Domestic/Private ❑ Gravel Pack racy _Type of Casing Specifications ❑ Public ❑ Other w I ❑_Delta. Depth of Grout Seal Type of Grout _ i I irrigation _..Approx. Depth I I Eastern urface Seal Installed by _ Repair Work Done ❑ Type of Pumpr H.P, State Work Done_ k Well Destruction ❑ Well Diameter Sealing Material (top 50') f Depth—i Filler Material IBelow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION i l REPAIR/ADDITION i I DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: 0 Number of bedrooms Character of soil to a depth of 3 feet: I Water table depth SEPTIC TANK ❑ Type/Mfg,I Capacity ! No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance tnearest: -Well Foundation Property Line i ;I LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to4nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS ❑ Distance 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 I rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following:g g g: "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." i s The appca ust call for all requ)rel ins cti s. Complete drawing ret,erse side. Signed Titl • pa a ' FOR DEPARTMENT USE ONLY i Application Accepted by Date Area r Pitor Grout Inspection by ate Final Inspection by Date E 1 3Additional Comments: VeA C1Stk 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 2009, S1k., CA 95201 INFO �pAMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. + EH 13-24 1 REV.I/x 51 --t9 3 —'---— EH 14 -26