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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE„ STOCKTON, CA r _ Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSU�D (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. r,[ Job Address City �� 1.bt Size PM rt Owner's Name)/��HCAddress � Phone� Contractor � License No6 13 7 3 Phone TYPE OF WELL/PUMP; NEW WELL 11;-� WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION C?-' SYSTEM REPAIR 0 OTHER Q DISTANCE TO NEAREST: SEPTIC TANK G ` SEWER LINES �e Q r DISPOSAL FLD. PROP. LINE FOUNDATION __/6 ' AGRICULTURE WELL OTHER WELL l DO r PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 9I Domestic/Private XGravel Pack EllTracy Type of Casing_ 1 Specifications ❑ Public 'er Cl Delta Depth of Grout Seal Type of Grout,' I I Irrigation Approx. Dept i I Eastern Surface Seal Installed by Cr u Repair Work Done Ld' Type of Pump 1 H.P. 3 State Work Done Well Destruction iJ Well Diameter Sealing Material atop 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION f 1 REPAIWADDITION I 1 DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) 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. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1 1 Depth Size Number SUMPS L-1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 1) 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." Contractors 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 all for I re uired inspections. Complete drawing on reverse side, Signed X 'l(•[ itle: i/!/ _ Data:, �J /� Application Accepted by FO EPAfiTMENT USE ONLY�/ F�G Date Area � v Pit or Grout Inspection by '� Date Final Inspection pb/y bat Additional Comments: � � -7` ' /'� / r� —_*6 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 8234104 Z ❑ Tracy 835-6385 Applicant - Return all_co ies/toEAvironment,��'Health Permit/Services �a�elton�v ., P.O. Box 2009, Stk., CA 95201 1I/ 'fC,� GC 3 ,�/ T//sem IFEE O AMOUNT DUE AMOUNT REMITTED CASH K9 RECEIVED BY DATE PERMIT'NO. +.EH 13.24(REV.l/11 51 EH 14-26