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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 12091 466-6781 PERMIT EXPIRES 1 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address � Cit Lot Size PM � r Owner's Name Address y r z { '�''� / Contract r✓� Address License No!„ C2_Z4_, Phone TYPE OF WELL/PUMP: NEW WELL ❑ -W.ELL_REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ Y SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE_WFLL_ - OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca -041a. of Well Excavation Dia. of Well Casing .;,- ❑ Domestic/Private ❑ Gravel-Rack ❑ Tracy Type,of Casing Specifications M Public -P Other '} n Delta Depth of Grout Sealt, .. 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 501 Depth Filler Material (Below 501 0 TYPE OF SEPTIC WORK: NEW INSTALLATION FIF PAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve:' Residence' Commercial ther r x Number of living units: Number of bedr om. Character of soil to a depth of 3 feet: Water table depth t,1 SEPTIC TANKType/Mfg Capacity No. Compartments PKG. TREATMENT PLT. EJ l r / Method of Disposal Distance to nearest: Well s -- Foundation Property Line � f f w LEACHING LINE No. & Length of lines C16Total length/size FILTER BED ❑ Distance to nearest: Well_: �_- Foundation ��/ Property Line SEEPAGE PITS Depth Size Nufnber SUMPS ❑ Distance to nearest: Well _ Foundation JO 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 applicant muall for ail re fired ' spectians. Complete drawing on reverse si j ZU6 Signed X Title: Date: FORDEPARTMENT USE ONLY Application Accepted by �~ OZ ly1Date Area 1,Pft or Grout Inspection by Dote Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 636-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK 0 INFO CASH RECEIVE[] BY GATE PERMIT NO. �( *.EH 13-24(REV.5/H5) / +�3 EH 1429