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j l a 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 heieby 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 City Lot Size PM Owner's Name Address * /"i" Phone ✓ A ContractorAddress icense No. y_ hone TYPE OF WELL/PUMP: y; N W WELL ❑ WELL REPLACEMENT ❑ STRUCTION A PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ -- 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 r ❑ Domestic/Private ❑ Gravel Pack d Tracy Type of Casing Specifications \\ {`l Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout r: XI Irrigation �Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well DestructionWell Diameter �1 Sealing Material trop 50'1 _C� { Depth Filler Material (Below 501 � as � M TYPE OF SEPTIC WORK: NEW INSTALLATION I'1 REPAIR/ADDITION I I DESTRUCTION I 1 {.No septic system permitted if public sewer is available within 200 feet.) i 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 ) I LEACHING LINE ❑ 'No. & Length of lines Total length/size FILTER BED ❑ ~.Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I i-Depth Size Number SUMPS ® ;Distance to nearest: Well Foundation 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 t 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 r 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 applicant must call r all-required inspections. Complete drawing on reverse side. i Signed X Title: _1d4Da t e'?'-2 r E R DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date-.Final Inspection by =n. Tf Date Additional Comments: /a Ilk ❑ Stk 466-6781 0 Lodi 369-3621 ❑ Manteca 823-7104 El Tracy 835-6385 "q( Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 952ok� Rk�C�S=�� CK 4 1J INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIV NO. + EH13-241AEV.rind EH 14-28 ��