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APPLICATION FOR PERMIT 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.. f wooc% ggggJob Address v ' 14 0buV� ----- City Lot Size PM �fVP tubo - 2? - Owner's Name Address Phone W ContractorOf��IC �U Address �GoJ 11 +'��.. License N �� Phone_ &`-' _4 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 SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1-1 Public I-I Other Cl Delta Depth of Grout Seal .. Type of Grout _ I I Irrigation --Approx. Depth l I Eastern Surface Seal Installed by _ Repair Work Dane L7 Tjcpe of 5:e�: H.P. State Work DoneWell Destruction Well DiaSealing MaterialItop 50'IDepth Filler Material (Below 501 �, TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIRIADDITION I I DESTRUCTION i I (No septic system permitted if public sewer is � available within 200 feet.) Installation will serve: Residence_ Commercial Other r Number of living units: Number of bedrooms— Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity Np. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line 4 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line ell SEEPAGE PITS l I Depth Size Number SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ hereby "ce y 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 r ations of the San Joaquin Local Health District. Home own4r of licansed 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 er�on in such m nn as to Dec esubj t to workman's compensation laws of California."Contractors hiring or sub-contracting signature certifies the flowing: "I cert"y t t in a pe rmanc of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of 1"ornia." The appli f a e ' d in i s. C plata drawing on ve eI`de. Signed X Title: Date: v FOR (DEPARTMENT USE ONLY ! f Application Accepted by Date7_ ` Area Pit or Grout Inspection by Dat Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 Q 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 FEE INFO AMOUNT DUE AMOUNT REMITTED ASCK H RECEIVED BY DATE PERMIT'NO. ♦-EH 13"24(REV.t/it 51 EH 14-25