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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON 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.548 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. .- !(it17 Job Address o .�3e .s � CityLot Size PM �n" / Owner's Name t7�`i !� Address • G/iD Phone Contracto l/.0 Address/� icen � /~ � Phone; a/ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER K DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE a! FOUNDATION AGRICULTURE WELL OTHER WELL PITS/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 n Public Cl Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation --Approx. Depth l I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H,P. State Work Done 1 Well Destruction "P� Well Diameter 62 Zig Sealing Material atop 50'I Depth Filler Material lgelow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION t 1 DESTRUCTION i I (No septic system permitted if public sewer is available wi&hij2P0 feet. I t ` 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 Capacity No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well foundation Property Line LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS D 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 agen ' ignature 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 iagrier as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: " cert' that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of Califor The applicant st c I all re ire }inspections. Com late drawing on rever Sign X l Title: �� Date: 2� ' FOR DEPARTMENT SE ONLY Application Accepted by � +� �� ,/w��s�,�,, Date L_r � Area Pit or Grout Inspection by ��- " Date 42 Inspection Final Itiby , Data n Additional Comments: _43 ❑ Stk 466-6781 Q Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 tG //dr11 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 962CL1 � EEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE CCYY PERMIT'NO. INFO ! C CASH • EH 13.24(REV.1/R 5) EH 14-26 JJ /