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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 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 sAwipe or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District./ Job Address �S City r4G Lot Size PM Owner's Name eve— J) e.ddress Phone Contractor u(le(` Address 00 80Y. License No.a15__- Phone.` TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION D SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE y FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i 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 — M Public 1-1 Other 11 pelta Depth of Grout Seal Type of Grout I ! Irrigation _.-Approx. Depth I 1 Eastern Surface Seal Installed by �1 Repair Work Done ❑ Type of Pump H.P. State Work Done_ 4 Well Destruction Cl Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATIONREPAIRIADDITION l I DESTRUCTION i I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Re�jidence _ Commercial— Other Number of living units: j Number of bedrooms Character of soil to a depth of 3 feet. Water table depth SEPTIC TANK Type/Mfg G� rapacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation 4io Property Line LEACHING LINE LRI—No. & Length of lines 10 C Total length/size goo � �i FILTER BED ❑ Distance to nearest: Well Foundation,_ _ Property:Line SEEPAGE PITS 1 1 Depth Size Number SUMPS Ll 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 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: "1 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 for all re 'red inspections. Complete drawing on reverse side. r�-� r� Signed X Title: -o—� 'JDate : F DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection byDate Final Inspection by Da y Ud f Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH � EH 13-24(REV.r i H 5) � EH 14-25 _,