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C APPLICATION FOR PERMIT r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 9 YEAR FROM DATE 'ISSUED (Complete in Triplicate) . F 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. -27 f Job Address Y "� City r Lot Size PM Owner's Name 5 Address ,I � �'�" Q ^Phone a Contractor BE V Address icense No. ll 3 Phone uY �1� TYPE OF WELL/PUMP: U NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.f� PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 6* ( ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private Gravel Pack XTracy Type of Casing Specifications ❑ Public 1] Other LlDelta Depth of Grout Seal T pe of Grout I ❑ Irrigation ---Approx. Depth LlEastern Surface Seal Installed by Repair Work Done ❑ Type4of Pump H.P. o State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') ti Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.l Installation will serve: Residence— Commercial_ Other t Number of living units: ' Number of bedrooms q Character of soil to a depth of 3 feet: Water table depth \ i SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ! PKG. TREATMENT PLT. ❑ Method of Disposal } Distance to nearest: Well Foundation Property Line F k A LEACHING LINE ❑ _No.'& Length of lines Total length/size FILTER BED ❑ i Distance to nearest: Well Foundation Property Line r i SEEPAGE PITS '❑ Depth -- Size Number SUMPS ❑ Distance to nearest: Well ` Foundation Property Line DISPOSAL PONDS ❑ 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. 4' , 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." i 4 The applicant ust call for ell require spections. Co .plate drawing on raver a sid . ` i (� SignedDate: Title: / FOR DEPA TMENT USE ONLY ; Application Acceptedby Date Area '0'7 s F J /� Date Pit or Grout Inspection by Date Final spection by � Additional Comments: 6 ❑ Stk 466-6781 Lodi 369-3fi21 Manteca 823-7104 ❑ Tracy 835-638.5 Applicant- Return all copies to: Environmental 41th 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 + EH 13-24(REV.i/a 5) EH 14-26