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r APPLICATION FOR PERMIT / SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 12091 466-6781 �` PERMIT EXPIRES 1 YEAR FROM DATE ISSUMIL (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. I' Job Address g 7� City Lot Size PM Owner's Name Address 22 756 6�• �� +�[* Contractor's Name License No. Phone S' TYPE OF WELL/PUMP: EW WELL WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK R SEINER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL—fes PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ♦/ 30 El Industrial El Open Bottom C1 Manteca Dia. of Well Excavation Dia. of Well Casing `4 Domestic/Private )e Gravel Pack ❑ Tracy Type of Casing Joyd" Specifications ♦ ❑ Public ❑ Other ❑ Delta Depth of Grout Seal 'W Type of Grout �) ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done J Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) 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 ❑ Type/Mfg Capacity No. Compartments Q PKG. TREATMENT PLT. ❑ 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 ❑ Depth Size Number — SUMPS ❑ Distance to nearest: Well Foundation Property Line G 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. 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 aCallfnia." The appli ncall for all r fired i ctions. Complete drawing on reverse sidge Signed Title: Date: �T FOR DEPART ENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date 6 Final Inspection by Dat1 Additional Comments; ElStk 466-6781 ❑ Lodi 369-3621 El Manteca 823-7104 racy 835- • Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box r FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY Ego' R IT NO. INFO C 13-24 fREV.10183] A3 1�l C C (�-y� S t ,�O