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APPLICATION FOR PERMIT j SAN JOAQUIN LOCAL HEALTH DISTRICT _ 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED IComplete in Triplicate) Application is hereby made to the San!Joaquin Local Health District for a permit to construct and/or install the work here'iii;described.'This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1B62 for well/pump and the Rules and,Regulations ofithe San Joaquin i Local Health District. i? � ��t c Job Address c�'�""-J City- Lot Size PM t Owner's Nam esQ �.S � --` Address Phone Contract� _hL, ' _Address L(o _. a�License Nd6� Phone ! 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 [I Industrial ❑ Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing `Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other Ll Delta Depth of Grout Seale Type of Grout . 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 Stop 501 f� Depth Filler Material (Below 50') V i TYPE OF SEPTIC.WORK: NEW;INSTALLATION l 1 REPAIR/ADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is y available within 200 feet.) Installation will serve: -Residence ..r Gommereial Other 'n k Number of living units: Number of bedrooms V t Character of soil to a depths 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. &�Lerigth of`Iines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line £s SEEPAGE PITS i I Depth Size Number SUMPS LI"^Distance to nearest: Well Foundation Property Line 3 DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accor6 ce with.-San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Di%trict. Home hwner 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 l 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." j The applicant must call for au required inspections. Complete drawing on reverse side. Signed A Title: Date: � � _-- F R-D PARTMENT USE ONLY Application Accepted by Date Z Area /0 Pit or Grout Inspection by Date Final Inspection by Date / I , 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 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH a EH13-24(REV. H51q��, P EH t4-2a r _k