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' APPLICATION FOR PERMIT r V� SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA 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 No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. �474 Job Address � City Size PM Owner's Name 4'ZddressS 49 Phone 41 Contractor 1 P- ddress 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 PETS/SUMPS INTENDED USE TYPE OF WELL PROBLEM.AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications u . M Public M Other Ll Delta Depth of Grout Seal Type of Grout ! I Irrigation --Approx. Depth i1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ [� Well Destruction Well Diameter r� Sealing Material (top 50'1 C-4; n � C Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I.i REPAIRIADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.l C1 Installation will serve: Residence______ Commercial____ Other Number of living units: Number of bedrooms l 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 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED s ❑ Distance to'nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number ` SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I herebycertify 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 laws of California." The applica m t call for all r quir in ctionst Co plete drawing on reverse side. �^ Signed le: Date: ~ �a FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date 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 * w INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. +.EH 13.21[fltlr.find ,�� ff / // r� `40 '�� EH 1/-28 ` L�`✓</ /�