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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ` 9601 E. HAZELTON 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 fo ell/pump and the Rules and Regulations of the San Joaquin Local Health District. Jab Address Ci �� ' PM .Owner's Nam /r Address a Phone ZO Contractor's Name License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ ' .'WELL REPLACEMENT ❑ DESTRUCT( r _ AMOUNT DUE l ON ❑ DATE 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/ Private ❑ Gravel Pack ❑-Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Del a', Depthr of Grout Seal Type of Grout ❑ Irrigation �pprox. Depth ❑ Eastern Surface Seal Installed by . Repair Work Done . ❑ Type of Pump H. P. State Work Done Well Destruction ❑ Well Diameter ; Sealing -Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION Qt=R PAIR/ADDITIO pESTF I, Installation will serve: Residence, Commercial Other Number of living.units: Number of bedrooms) Character of soil to a depth of 3 feet: (No septic system permitted if public sewer is available within 200 feet.) Water table depth _ SEPTIC TANK ❑ Type/Mfg `� t Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line rLEACHING LINE No. & Length of lines _ ToJal length/size FILTER BED Distance to nearest: Well Sa Foundation a Property Line 3 0 SEEPAGE PITS ❑ Depth Size SUMPS ❑ Distance to nearest: Well DISPOSAL PONDS ❑ Number Foundation Property Line - r f ^ 1 hereby certify that f have prepared this application and that the work wiil 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-caritracting signature f certifies the following. "I cartify that in the performance of the work for yvhich this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." R - The applica st call for e m tions. Complete drawing .on revefse side. i Signed Title: Date: -Z �_. . ��'vv's"'r-- FOR DEPARTMENT USE ONLY u !� Application Accepted by Date a �Z! r�/ Area O� Pit or Grout Inspection by nAtA, _ Final Inspec 'on by Date � n �• l'(Q,v bDw 0i^�t,� <_.. Additional Comments: �-- / + ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy. 835-6385 Ka I X7 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 + EH 13-24 (REV. 10183 EH 1428 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT`NO.