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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. A' r� Job Address �J / /l �lf,�../ 'iY Q- City Lot Size PM Owner's Name d l �t— #wTAddress 5r Phone Contracto Address Fd L 45Q=wra- icense No.�-SJ,9e_? Phoneme 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 F" Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout .1 1 Irrigation _..Approx.IDepth 1.1 Eastern Surface Seal Installed by r Repair Work Done ❑ Type.of Pump H.P. jfl�S C State Work Done k Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') �_ a TYPE OF SEPTIC WORK: NEW INSTALLATION I-1 REPAIR/ADDITION I 1 DESTRUCTION I I INo septic system permitted if public sewer is-w 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 r LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance tit nearest: Well Foundation Property Line • F i SEEPAGE PITS I I Depth Size Number CCD T G� i., . SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL'P4NDS ""❑ ""` "^��' `°' - -��- -- - -�ENVIRONMr-NTAL-HEAJH-_ .,�. I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin�c ��r�iws, and rules and regulations of the San Joaquin Local Health Di1trict. 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 eempIoV-any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature `carrtifies`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 applicant ipasrZWfdr all requir ins tions. Complete drawing on reverse side. Y 3 (�T^ Signed 7 X ` �( ��.. Title: --- Date: 2 ` �/ Q FOR DEPARTMENT USE ONLY 9 r Application Accepted by Date Area CJ Pit or Grout Inspection by Date Final Inspection by Date 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 FEE INFO AMOUNT DUE }E AMOUNT REMITTED CK CASH RECEIVER 8Y DATE PERMIT'NO. + EH 1321(REV.r t e s� F - r a EH 11-2e `' q D o -33�