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e APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ` 1601 E. HAZEL T ON AVE., STOCKTON, CA ` 1 Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 wev/pump and the Rules and Regulations of the San Joaquin Local Health District. /� Job Address r City s Lot Size Owner's Name 10 PM ��_ Address Phone �' '� -- ContractorAddress icense No, Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACE ENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM-REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LI NE FOUNDATION AGRICULTURE WELL, OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS (iIndustrial ❑ Open Bottom ElManteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel-Pack ❑ Tracy.- Type of Casing Specifications ('1 Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout f I I Irrigation, ) --Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Oone_ Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Flier Material (Below 501 — TYPE Of SEPTIC WORK: NEW INSTALLATION 11 REPAIRIADDITION I DESTRUCTION I I tNo septic system permitted it public sewer is ,\ available within 200 feet.) iInstallation will serve: Residence__X Commercial _-- Other Number of living units: -.---( Number of bedrooms t t { Character of soil to a depth of 3 feet: �' Water table depth i SEPTIC TANKy ❑ Type/Mfg* _ Capacity__ No. Compartments LA PKG. TREATMENT PLT. 11Method of Disposal Distance-to`nearest: Well Foundation Property Line LEACHING LINE ❑ No"& Length of lines,, Total on th/si 'd ze �� FILTER BED E] Distance to'nearest: `.W611 Founatibn �� Property Line r. ..A ! Number � SEEPAGE PITS l I Depth "" , .--Size_ SUMPS L] Distance to nearest: Well :- Foundation_-�� Property Line DISPOSAL PONDS ❑ - t I hereby certify that I have prepared.this application and that the work will"be done in accordance with San Joaquin county ordinances; state taws, and rules and regulations of the San Joaquin Local Health District.' r Home owner or licensed agent's signature certifies the following: "I certify that in the performance of th6 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 Californi ' The applicant mu ca for e i pec' ns. Complete dr Ing on reverse side. " `i Signed X Title: 4t Date: FO EPIULTUENIALSE ONLY I s Application Accepted b; Date Area Pito Grout inspection by Date Z �QO 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 s - FEE AMOUNT DUE AMOUNT REMITTED C FI RECEIVED 6Y DATE PERMIT'NO. +.EH 13INFO dd 24(REV. /h 51 T1 c- h.-369 EH 14-28