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APPLICATION PLICATION FOR PERMIT . SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (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�Re�ulatiq+s of the San Joaquin Local Health District. I.J / �7 �^ r h /) �h M �' !/ City�l0 C l�r Lot Size !f CJ PM I Job Address I �� ../ > Phone Ownerls Name /' "= L� - Address T fi Contractor Address License No. Phone_ 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 PETS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Oen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Q industrial P ❑ Domestic/Private L] Gravel Pack ❑ Tracy Type of Casing Specifications _ kA {l Public CI Other [] Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth 1 I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction" LJ Well Diameter Sealing Material Itop 50'1 Depth I Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION l em permitted if public sewer is NO septic Sys[ available within 200 feet.) Installation will serve: Residence='1 Commercial, Other Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: SEPTIC TANK El Type/Mfg l Capacity No. Compartments PKG. TREATMENT PLT. C7 Method of Disposai j Distance to nearest: Well Foundation Property Line ' E _ LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest. Well Foundation Property Line r r Number SEEPAGE SEEPAGE PITS I I Depth Size SUMPS ❑ Distance•,to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ { hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an rules and regulations of the San Joaquin Local Health Diltrict. 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 to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature employ any person in such manner as 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 must call for all required inspections. Complete drawing on reverse side. 4 Signed Title: Date: ` Zs �� t FOR DEPARTMENT USE ONLY Application Accepted by — 12 Date Area l � - g t Pit or Grout Inspection by Date Final Inspection by Data Fi 1 Additional Comments: I ❑ Stk 466-6781 ❑ Lodi1 0 Manteca 823-7104 L3Tracy 835-6385 ' Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I. FEE CK RECEIVED BY ;DATE PERMIT'NO, 1 INFO AMOUNT DUE AMOUNT REMITTED CASH o +.EH'13-24IREV.r/ns1 4 EH,14M12e