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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601.E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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. ,e � r Job Address �06 .44 / City Lot Size PM �� 6 Owner's Name � � `' �G � 7 Q ContractorT (, Address License No. 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 SPECIFfCATIONS — Li Industrial ; ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f'l Public x Cl Other Cl Delta Depth of Grout Seal T _ Type of Grout I i lrrigatioW: I —.Approx. Depth id Eastern Surface Seal Installed by _ Repair-Work pone ❑ Type of Pump E H,P. . State Work Done_ ,J �t w Well Destruction X Well Diwr eter 1 Sealing Material Itop 501 g ,,,e Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is i 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 T ,C city No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Foundation Property Line LEACHING LINE ❑ N ength of lines +Total length/size FILTER BED Distance to nearest: Well Foundation_..;,-. Property Line l SEEPAGE PITS i I Depth Size f Number SUMPS Ll 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." 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 taws of Calif o nia." The applicant 11 call for all require 46 pectione--Complete drawing on reverse side. Signed X 4 _ Title: Date: 'r ` ( FOR DEPARTMENT USE ONLY Application Accepted by 414� _, Date — F 7 Area Pit or Grout Inspection by Date Final Inspection by Datef� 7 Additional Comments: IdSt • ]Stk .}y�� El Lodi 3&9-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant-et rri'Stf copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK H RECEIVED 8Y4's INFO DATE ER;t� O. + EH 13-24(REV.fiH51 S, V 73.70 EH 14-2e IV