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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. W054 oYo x..Q Job Address 5(� __pI � � �-� City o�o Lot Size PM 40viner's Name (i It01d �/'U + Address��p r� �� / 4W 91�Za l Phone Contractor Address -7 q!3? r !VL%t9S.xi cense No: 2411W-1-Phone 337"11r3id TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLDff� PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIF.I.CATIONS rj i ❑ Industrial Open Bottom ❑ Manteca Dia. of Well Excavation- Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing �� ` ' Specifications 'a.tt M Public F1 Other f-] Delta -Depth of Grout Seal �"�W�- E-Type of Grout_4 _ �Q'Irrigatian �!Approx. Depth I i Eastern Surface Seal Installed by Repair Work Done ❑ Typeof Pump H.P. Stat Work Done_ {" Well Destruction ❑ Well Dia Sealing Material Stop 50'1 Depth - Filler Material (Elel000ll TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l 1 DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial____ Other Number of living units: Number of bedrooms f 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 A. Total length/size FILTER BED ❑ Distance to nearest: Well f Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS I-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 Dr'ktrict. 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, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, l shall employ persons subject to workman's compensa- tion laws of California." The applicant must a for all r 'red ' spections. plete drawing on reverse side. Signed X Title: _ � _ Date: , FOR DEPARTMENT-UgE ONLY !� Application Accepted by T Date Area- Pit or Grout Inspection by Date Final Inspection by Data Additional Comments: &I S 3 �"F.3 ❑ Stk 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, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT-NO. t.EH 13-14)REV-rix51 'L2 EH 14-20 6