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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 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 Regulations of the San Joaquin Local Health District. Job Address ,F1�U77 City eiga&t Lot Size PM f Owner's Name Address Phone Contractor � L Address. &!U !W /6? ^License No.- Phon& TYPE OF WELL/PUMP: NEW WELL El WELL REPLACEMENT ❑ DESTRUCTION ❑ 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 ' 130 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 0 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F1 Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth l I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work-Pone Well Destruction ❑ Well Diameter Sealing Material atop 501 Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION DESTRUCTION ( I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence—' Y Commercial -Y Other - g Number of living units: Number of bedrooms " Character of soil to a depth of 3 feet: � Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation Property Line . LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth 9�ySize ll !� Number foe SUMPS tpe Distance to nearest: Well Foundations 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; and rules and regulation of the'SanaJoaquin 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-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." '' 5 The applicant must call for all re uired inspections. Complete drawing on reverse side. Signed X �.. Title: Date: R DEPARTMENT USE ONLY Application Accepted by t / _'i7_ Date r Area ✓ f Pit or Grout Inspection by Date Final Inspection by Date F fe Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2008, Stk., CA 95201 f FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH + EH 13-24(REV.I/n 5) (�� 1 l k C -7 r3(,"]�/0i1 EH 14-28