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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL 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.' j Job Address D t ` f �� vCity Lot Size PM Y Owner's Name ca ! Address f Phone Contract r ,aG" � ' f 1 Address r�// License No�7 z ��'Phone TYPE OF WELL/PUMP: J' NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ll _ PUMP INSTALLATION.❑, SYSTEM REPAIR El OTHER ❑— ' �� s DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES til SPOSAL-FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM EA STRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Trac e'.of Casing Specifications • -M Public -- - — L) Other -�{7- elta Dept of Grout.Seal -- -Type of Grout - —---— - i I Irrigation --Approx. Depth I Eastern_ Sutiace_ eal Installed by _ Repair Work Done ❑ Type of Pump H.P. ^_ State Work bone_ Well Destruction ❑ Well Diameter — -Sealing Material-(top-50'),' Depth _der Material iBelow 50'1 TYPE OF,SEPTICWO'RK: NEW INSTALLATION I'l `A�EPAIR - 'DDITIONW DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will-serWe_Residence A Commercial_,.Other Number of living units: _/— Number of drooms j Character of,soit-to a depth of 3 feet: -" Water table depth SEPTIC-TANK' ❑'fType/Mfg 5 Capacity No. Compartments PKG. TREA,TMFNT,PL-T.:D f — — 'i Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line _ SEEPAGE PITS _ Depth_ Size�� Number SUMPS Cl Distance to nearest: Well Foundation 40` 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 laws of California." The applican ust call f all re ired inspections. Complete drawing on reverse side. Q Signed X Title: \11;,Pf Data:(27 l 0 Ct FOR DEPARTMENT USE ONLY Application Accepted by Date Area��_ j 1z it r Grout Inspection by Date inal Inspection by�� o`7e� Dat 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 A FEE INFO AMOUNT DUE AMOUNT REMITTED CCK 4 RECEIVED BY DATE PERMIT'NO. + EH 111-?8\326(REV,1/R5) EH 3 -S� C 8—kc h�