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APPLICATION FOR PERMIT , SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA 4 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 � ea� �L City o Size PM Owner's NameAddress - � Phone Contractor Address rcense No. P�honew 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 i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial I❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel PackC3Tracy Type of Casing Specifications [I Public !� Public Other I ❑ Delta Depth of Grout Seal Type of Grout __ \1 ? I I Irrigation �,.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H,P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') _ TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION i-I DESTRUCTION (No septic system permitted if public sewer is i vailable within 200 feet.► Installation will serve: Residence_I Commercial Other i Number of living units: Number of bedrooms { Character of sail to a depth of 3 feet:41 Water table depth } SEPTIC TANK ❑ Type/hAfg, Capacity No. Compartments PKG. TREATMENT PLT. ❑ {�<� I 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 I Depth Size Number s SUMPS ❑ 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 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." Contractors hiring or sub-contracting signature t 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 tion laws of California." compensa- The applicant tall r all re inspections. Complete drawing on reverse side. Signed X if Title: Date: 2,y' - t FOR DEPARTMENT USE ONLY Application Accepted by — \ Data Area AS— Pit or Grout Inspection by Date Final Inspe�tionby Date Final Inspec=tion by2-*e �ate 6140 r-A"VM d re?svtey{rf. /G4.-+P�f rocs sJas ,e+� Additional Comments: r v ❑ Stk 466-6781 ❑ Lodi 369- 1 ❑ 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 f i� FEE AMOUNT pUE AMOUNT REMITTED CK INFO RECEIVED BY DATE PERMIT-NO. +.EH 13-24(REV.I/H 5) EH 14-26