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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA VU 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 Po.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Healt`h0District,Lr -+ `i ' S rbJ Job Address 7 -0-1wL `y/ s E-City Lot Size PM Owner's Name NJ �`' Address ��/ �+ Phone ... Contractor dress �` ' License No. Phan 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 ( n \'iF INTENDED USE TYPE OF WELL . PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Ilia. of Well Casing Q ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F`1 Public (7 Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation // Approx. Dep t+`l yEastern Surface Seal Installed by Repair Work Done L� Type of Pump II'f� H.P. / State Work Done 7 wJ rn Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material IBelow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION f I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation - ill serve: Residence— Commercial_ Other Number of living 'Is: Number of bedrooms Character of soil to a dep 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 i I Depth Size Number SUMPS C1 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 ordinan 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 certif that in the performance of the work for which this permit is issued, I shall employ persons subject to work an's co pensa- tion laws of Ca fornia.' The applica ust c fo I re (ed s ctio Co plate drawing oq rw�e side�� Signed X Title: [1/� � — Date: FOR DEPARTMENT USE ONLY f�q Application Accepted by Date?' Z )—�� Area v Pit or Grout Inspection Date Final Inspection by ZY442t Datea 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 95201FEE 1 INFO AM�O+U+NT DUE AMOUNT REMITTED CASH K 11 RECEIVED BY DATE PERMI-Ty'N0. + EH 13-241REV.rind EH 14.26