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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 e .. f. .t: • PERMIT EXPIRES 1 YEAR FROM DATE ISSUED .471 {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. ' Job Address , ✓ �L 'r City �/aCof Size PM Owner's Name ��,� !_'.< Address „ � �~ �/_ Phone / f Contractor J Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ h. PUMP INSTALLATION Elw SYSTEM REPAIR [IOTHER Ll DISTANCE TO NEAREST: SEPTIC TANKEWER LINES DISPOSAL FLD. PROP. LINE ' FOUNDATION AG CULTURE WELL OTHER WELL ! PITS/SUMPS / INTENDED USE { TYPE OF WELL PROBLEM AR CON UCTION SPECIFICATIONS J I ❑ Industrial j F1 Open Bottom ❑ Manteca ra. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy T e of Casing Specifications r ❑ Public ❑ Other ❑ Delt Depth f Grout Seal € Type of Grout F] Irrigation ---Approx. Depth�EUIstern Surface Seal Installed.by Repair Work Done ❑ Type of Pump H.P. Stafe Work;Done Well Destruction ❑ Well Diameter Sealing Material /top 50'I i 41 Depth Filler Material /Below 501 ' TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ OESTRUCTION (No septic system permitted if public sewer is r f available within 200 feet.) -Installation will serve: Residence_ Commercial_ Others Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: s ater table depth 1 j. SEPTIC TANK ❑ Type/Mfg ; Capacity 1 No. Compartments PKG. TREATMENT PLT- ❑ ; Method of Disposal > i +, Distance to nearest: Well•- .-�—Foundation- --=---jProperty Line LEACHING LINE ❑ No. & Length of lines r Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line +�. t r SEEPAGE PITS ❑ Depth Size Number R .L SUMPS ❑ Distance to nearest: Well Foundation Property Line'' ' DISPOSAL PONDS ❑ - - - /,hereby-certify that-I-have prepared this applicationand 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 subject10 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 permits issued, I shall employ persons subject to workman's compensa- tion laws of Celifor ' The applican ust ca for all r uired inspe ns. Complete drawing on arse side. Signed. - - �.rtle e t Date: :3 FO RTMENT USE ONLY 5 Application Accepted by Date rea Pit or Grout Inspection by Date Final Inspection by Date �f Additional Comments- s 0 l ❑ Stk 466-6781 ❑ Lodi 69-3621 r ❑ Manteca 823-71 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services.1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 . INFO FEE AMOUNT DUE AMOUNT REMITTED K RECEIV.ED.BYnj pATE i — PERMIT•NO. i EH 3-24 I EH 14-29/REV.i H sJ rl .1(�6