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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT '-'1 .l 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 11,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. (� I V Job Address O V `-'r.�Lt! City ��/� Lot Size PM Owner's Name v 1 � Address ' O V t^' Phone Contractor 0,11W" fIt �b` Address Lam+4. . License No. v Phone �� 4 TYPE OF WELL/PUMP: NEW WELL ❑ 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public n 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 Done_ Well Destruction P--Well Diamete Sealing Material (top 501 .� Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Ci 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 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 11 Depth Size Number SUMPS Ll Distance to nearest: Well 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 lJandrules and reg tions of the San Joaquin Local Health Di1trict. Home owneror 'tensed a is signaturecertifies the following: "I certify that in the performance of the work for which this permit is issued, I sanot employ any rs n in suc m ner as to be a subje t to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the fCi I. ing:"I c rtif th t in a rmanc f the work for which this permit is issued,I shall employ persons subject to workman's compensa tion laws of C ornia." The appli st 11 r e in i C plete drawing on r rid Signed X Title: �I��'�— 6 Date: O FOR DEPARTMENT USE ONLY Application Accepted by fi�+�� v6/ Date Area �e Pit or Grout Inspection by Date Final Inspection by glan ate Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copiers to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CKRECEIVED BY DATE PERMIT'NO. INFO CASH / +,EH13.21(REV.1/x5) , ��C �/ zq b . EH 11-29 1