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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. Job Address q;DCite Lot Size PM p Owner's Name Address L Phone Contractor AddressV ft �yicense No. Phone, R)-5 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 I ❑ Industrial ❑ Open Bottom f ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public lel Other ❑ Delta Depth of Grout Seal Type of Grout _. I I Irrigation __-Approx. Depth ' l I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump . H-P. State Work Done _ 1 Well Destruction ❑ Well Diameter Sealing Material Itop 50 �} t Depth Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION l septic system permitted if public sewer is V �� available within 200 toot.) Installation will serve: Residence��Commercial�� er Number of living units: —]— Number of bedrooms f 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 near Weil undation Property Line t 1 LEACHING LINE ❑ No. & Length of lines o 6th/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 1 SEEPAGE PITS l 1 Depth Size Number SUMPS L71 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ s I 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.Di§trict.-.---4---• �. 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 C`Ce .' s the following: "I artify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws alifo nia." The applica m call f equir ins ion Co dra 'ng on verse side Signe - T-,J Date: AD NtAXEL)ARTIMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by ' Date Additional Comments: ❑ Stk 466-6761 ❑ Lodi 369-3621 El Manteca 823-7104 ❑ Tracy 835-6365 Applicant - Return all copies to: Environmental Heatth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 T - FEE MOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH ..EH 13-24(REV.t/n al � _n EH 14-26