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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephohe (209) 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 - t �-�` ^-r 1� '°'`rte - City Lot Size PM Owner's Name 1 Address 1 '� Phone Contractor ` ddress + License No. r AL Phone Us . 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 PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L1Industrial ❑ Open Bottom ElManteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications [`1 Public Cl Other n Delta Depth of Grout Seal Type of Grout-- I rout _.I 1 Irrigation --Approx. Depth ( II Eastern Surface Seal installed by Repair Work Done ❑ Type of Pumper H.P, State Work Done U' Well Destruction ❑ Well Diameter rl Sealing Material (top 501 . Depth Filler Material (Below 50') -- TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION i I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial-- Other Number of living,units: - Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal 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 I I Depth Size _ Number SUMPS L-1 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 rules and regulations of the San Joaquin Local Health Di'9trict. 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 toll ing: "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of Ca f rnia." The applie nt st call for a req sr d inspecti s. Complete drawing on rever e side Signed X Title: Date: FOR DEPARTM USE ONLY AF Application Accepted by , Date S q L 0 Area Wy Pit or Grout Inspection by Date Final Inspection by ate r . Additional Comments: _ ❑ Stk 466-6781 ❑ Lodi 369.3621 0 Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ` FEE AMOUNT DUE AMOUNT REMITTED I CK RECEIVED BY DATE PERMIT-NO. INFO CASH + EH 13-24(REV.i/R5)EH 14-26 ---s 1 / o19� 1