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APPLICATION FOR PERMIT Ih SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 l PERMIT EXPIRES i'YEAR FROM DATE ISSUED (Complete in Triplicate) I 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 Cbunty Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District: �7 Job Address / City Lot Size " / P u : � V E Owner's Name Address e7 • Phone C ire Contractor Address / , ce" e o. Phone TYPE OF WELL/PUMP: N.EW.WELL ❑ _ _ WELL REPLACEMENT ❑ DESTRUCTfON ❑ PUMP INSTAL TION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES �� DISPOSAL FLD. PROP- LINE FOUNDATION AGRICULTURE LE Lam- — —=-OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PR LEM A CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ eca Dia. of Well Excavation Dia. of Well Casing E71Domestic/Private E] Gravel Pack Tracy T of Casing - Type 9 Specifications ❑ Public Ll Other f 1 Delta Depth of Grout Seal Type of Grout _ I i Irrigation —.Ap x. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.-P. w --� .r�. -'State'Work-Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth p f Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION 1 3 DESTRUCTION (No septic system permitted if public sewer is t 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 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line .«I I 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 SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ i 1 hereby certify that I have prepared this application and that the_ workwillbegone 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 California." # s The applicant mu;callr 811 i3iq ire inspections..Complete.drawing.on reverse-side: Signed X - - rf Title: Date: ( FOR DEPARTMENT USE ONLY / Application Accepted by -Date C��I�` — -AreaC�3 �y Pit or Grout Inspection by ate Final Inspec Ion by Date �'1 Additional Comments: v r- 9rerle"/� ElStk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environr4ntel Health Permit/Services 1601.E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED INFO � CK RECEIVED BY DATEPERMIT NO. r EH 13-24(REV. 2 y EH 11-2f1 /7rL/ J