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APPLICATION FOR PERMIT SAN JOAQUIN'LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES1-YEAR FROM DATE ISSUED (Complete in Triplicate) eir 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 d d Ci Lot Size PM ' Owner's Name 7izrAddress — 'Phone j Contractor I� s cense No Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION El PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK I t SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION• AGRICULTURE WEL 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 Pack13Tracy Type of Casing Specifications C1Public ElOther - .1 ❑ Delta ; Depth of Grout Seal Type of Grout G ❑ Irrigation --Approx. Depth ❑ Eastern r Surface Seal Installed by .C Repair Work Done ❑ Type of Pump t H.P. State Work Done Well Destruction ❑ Well Diameter .# Sealing Material )top 501 C' Depth Filler Material (Below 501 r TYPE OF SEPTIC WORK: NEW INSTALLATION Iff REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence 4 Commercial— Other Number of living units: 4 Number of beOrris Character of soil to a depth of 3 feet: dr Water table depth SEPTIC TANK ❑ Type/Mfg ` Capacity _ No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal �. Distance to nearest: 4 Well _ Foundation Property Line LEACHING LINE No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well f�,o Foundation." Property Line�� t SEEPAGE PITS Depth y Size Number' SUMPS ❑ Distance to nearest: Welles 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 District. - r ..'. 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." The applicant m s call or all re uire in tions. Complete wing on a side. 4 �....�. ,. � Date: Signed Title: FOR•DEP T SE ONLY /, ` x� 1P / 7 Application Accepted by Date Are Pit or Grout Inspection by Final Inspection bye,/` ` Date Additional Comments: 4 ' ❑ Silk 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. li `P FEE AMOUNT DUE .'�; AMOUNT REMITTED CK CASH RECEIVED BY DATE _t. PERMkT`NO, • ' INFOY { 4 EH 13.241REV.1/851 �f19es EH 1426