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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA p Telephone (209) 466-6781 J►'i le 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 9 9 City C G Size PM Owner's Name w Address �)/�►�yA a Phone Contractor �L r Address ` cr Grd�^ License No. d o Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ y PUMP INSTALLATION ❑ SYSTEM REPAIR-)-< OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP..LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS l; INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 11 ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing C�_ ❑ Domestic/Private ❑ Gravel Pack LJ Tracy Type of Casing Specifications Public . O Other Ll Delta Depth of Grout Seal Type of Grout I I Irrigation Approx..Depth I I Eastern Surface Seal Installed by Repair Work Done ^ Type of Pump !!� H.P. < State Work {lone s— Well Destruction. ' ❑ Well Diameter -- Sealing Material (top 501 Depth t filter Material (Below 50'1 �— TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIRlADDITION l ) DESTRUCTION I i INo septic system permitted if public sewer is i available within 200 feet.) j Installation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: " Water table depth SEPTIC TANK L) Type/Mfg Capacity—. No. Compartments PKG. TREATMENT PLT. ❑ r _ =- Method of Disposal r � Distance to nearest: Well Foundation Property Line t LEACHING LINE ❑ No. & Length of lines t t Total length/size FILTER BED ❑ Distance to-nearest: Well ' 'Foundation Property Line M SEEPAGE PITS l I Depth t "Size Number SUMPS ❑ Distance`to nearest:' Well` S 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 r 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-contracting signature certifies the following: "I certify that in the performance of the work for w_hick__this permit is issued,I shall employ persons subject to workman'1compe ) tion laws of California." The appy t mus call for a!I require pections omelet swing on r w side.qSignedX Title: Date: A• 4 OR (DEPARTMENT USE ONLY Application Accepted by C. 1N� Date — + Area Pit or Grout Inspection by Date Final Inspection by Date G � � t Additional Comments: Ci Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca •'823-7104; �4 ❑ Tracy 5:836-6395 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I FEE MOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH rEH 3-24IREV53td C/ Z0e 10 4 YLO? EH 14-26