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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 1 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 gz 11 CityLot Size OPM Owner's Name Phone Contractor's Name /rise No. Phone TYPE OF WELL/PUMP: NEW WELL ❑r- WELL REPtACEMENTIOCl DESTRUCT ION ❑ ""F30TVIT�IFFSTAl-13mcm Ll EWREPAIR`❑' OTHER ❑ DISTACETO NEAREST: SEPTIC TANK, SEWER LINES DISPOSAL FLD. PROP. LINE •, FOUNDATION "' AGRICULTURE WELL OTHER WELL PITS/SUMPS '-INTENDED USES,. T TYPE OF WELL, PROBLEM AREA_CONSTRUCTION SPECIFICATIONS f1% ❑ Inddstrial " ❑ Open Bottom ❑ Manteca Dia. of Well Excavation` " ;. Dia. of Well Casing.k ❑:Upmestic/Pe ❑ Gravel Pack ❑ Tracy Type of Casing Specifications .� ❑ Public CI Other Ell Depth Depth of Grout Seal Type of Grout S y ❑ irrigation �ARp�'rox�Depth ❑ Eastern Surface Seal Installed by Repair Work Done } Type of Pump � H:� State ork Done Well Destruction , ❑XWell Diameter Sealing Material (top 501 `Depth Filler Material {Below 50'M TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION + 4(.No septic system permitted if public sewer is ¢ available within 200 feet.l Installation will serve: Residence_Commercial_ Other Number of living units: I Number of bedrooms� r Character of soil to a depth of 3 feet: ZIA14e Water table depth SEPTIC.Y-ANK El Type/Mfg �„Y"1/J Capacity" � No. Compartments PKG. TREATMENT PLTT❑ ��j''01 ! w if Method of Disposal - Distance to nearest: Well V 0'-- Foundation `+� Property Line LEACHING LINE Ej No. & Length of lines Total length/size a ! FILTER BED ❑ Distance to nearest: Well Foundation �� Property Line r I SEEPAGE PITS ❑ Depth Size Number I SUMPS ❑ Distance to nearest: Well Foundation" Property L-'ina - 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.-Contractors 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 applica at r II uired pec'ons. Complete a.Towing on pvqrse side. Signed X 4Title: Date: 4 FOR DEPARTMENT USE ONLY Application Accepted by Data f� Pit or Grout Inspection by Date Final Inspection by Date A� Additional Comments: t1S 1�Hs l�✓ I` ❑ Stk 466-6781 ❑ Lcoi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 1 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Or"Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT`NO. INFO CASH C•_ + EH 1428 EH 1324(REV.101831 J S v v