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I } *" APPLICATION FOR PERMIT SAN JOAO.UIN LOCAL HEALTH DISTRICT 1601 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 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. do Job Address V 0* t` �T City Lot Si;e, PIM a4 / Owner's Name. M�-"""" try1 ��'I` Address T� -" Phone " 'f-1 �`--1 r Contractor -V 'vn� Address i i License No. Phone +. TYPE OF WELL/PUMP: : NEW�WELL ❑ WELL REPLACEMENT,171 `DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE j FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS- ❑ Industrial ❑ Open Bottom ❑ Manteca 9 Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy i Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of"Grout Sea(, Type of.Grout F1irrigation �pprox.,Depth LlEastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P` F State Work Done i Well Destruction ❑ Well Diameter Sealing Material (top 50') Q Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) i, Installation will serve: Resident_e_F_Commercial_ Other- 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. ❑ s Method of Disposal Distance to nearest: Well Em Foundation Property Line t I } � LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line '✓ 1 - I SEEPAGE PITS ❑ ""Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 ' 1 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. @ Home owner or licensed agent's signature certifies the following: '1 certify that in the performance of the work for which this permit is issued, I shall not i 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." } t The applicant ust c I r all required inspections. Complete drawing on reverse side. a ` Signed Title: `t Date: " { FOR DEPARTMENT USE ONLY Application Accepted by _� Date U�2 7 Area 0 ,I Pit or Grout Inspection by Date Final Inspection by 1 Additional Comments: ❑ 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 r t FEE AMOUNT DUE AMOUNT REMITTED CAS RECEIVED BY DATE PERMIT`NO. -� f INFO I + EH 13-24(REV.t/BS)a5) I EH 14-28