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_4 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 City CQ 0 Lot Size PM Owner's Name �-�f= Address Y , / r Phone Contractor' F .Pf- Address 6J License No. •t-1 1 X Phone TYPE OF WELL/PUMP: NEW WELL/K,. WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑/ SYSTEM REPAIR ❑ ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. +nom-(��PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE - TYPE OF WELL PR BLEM AREA CONSTRUCTION SPECIFICATIO S �f f [I Industrial 11 Open Bottom anteca Dia. of Well Excavati T Dia. of Well Casing tomestic/Private ravel Pack ❑ Tracy Type of Casing Specifications Public r❑t Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation t4—fC_Approx. Depth LJ Eastern Surface Seal Installed by r Repair Work Done ❑ Type of Pump M.P. State Work Done Well Destruction F1Well Diameter Sealing Material (top 501 �j I Depth Filler Material {Below 501 1 1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION 0 (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 a 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 ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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." Contractor's 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 st all for II r ui d inspections. Complete drawing on r erre side. r F Signed Title:�_, Date: 1!� FOR DEPARTMENT USE ONLY -) �J Application Accepted by Date - 3 - / Area C-1 Pit or Grout Inspection by // Date Final Inspection by Date Additional Comments: ,G G ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83540% I Applicant- Return all copies to: Environmental Health Permit/Servioes 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT'NO. + EH13-24IREV. /asl EH 1428 ;, r