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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 111 (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 City0Lot Size PM ;t Owner's NameUl'il°�- NIC,_ Address (� Phone ii 1 r Contractor J Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION A PUMP INSTALLATION ❑ SYSTEM REPAIR 1❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK' SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial DQ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout )K Irrigation —.-Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done ❑... Type of Pump H.P. State W rk Done Well Destruction '- �; Well Diameter f Sealing Material (top 50'1 sr Depth _33 Filler Material (Below 501 —_ TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial Other Q\ Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth f� SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments V PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line f LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line i SEEPAGE PITS l I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this,applicationand that the work will be done in accordance with San Joaquin county ordinances, state laws, r rules and regulations of the San Joaquin.Local Health DFstrict. 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 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." I The applica must I for all required inspections. Complete drawing on rev/`arse side. /-� Signed X el Title: h � rM Date: f 12 Q" fi OR DEPARTMENT USE ONLY n Application Accepted by _ ��- r�-� �; Date t-- CID Area ' i Pit or Grout Inspection by �t Date Final Inspection by Date Additional Comments: I❑ 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 AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT NO. INFO /f Q +.EH 13-24/REV,I/n sr 3 S I�� I I/ % EH 14-26