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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 sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address —M6 MG �a�� City S44e of Size PM Owner's Name dress `� Phone Contractor .•Addres`s License No 1f 0 71 Phone 6W—A" TYPE OF WELL/PUMP: NEW WELL © WELL REPLACEMENT ❑ DESTRUCT[ i PUMP INSTALLATION-[-]- SYSTEM REPAIR ❑ OT DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL CLD. PROP. LINE FOUNDATION AGRICULTURE WELV 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing` " Specifications i� Public ❑ Other Cl 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 Well Destruction ❑ Wel[ Diameter Sealing Material (top 50') Depth Filler Material (Below-501 TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION I I DESTRUCTION i INo 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 f` r PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well f=oundation Property Line ! `� r ..LEACHING LINE ❑ No. & Length of lines ,Tota[ length/size f FILTER BED ❑ Distance to:nearest: Well Foundation Property Line ^ SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation^"*'x' `L- 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: "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 for all required inspections. Complete drawingon rave a side. Signed X Title: ,� • Date: DE TINENT USE ONLY { Application Accepted by Date .� Area -7 Pit or Grout Inspection by / Date Final Inspection by v Date f b Additional Comments: ,lb`�6 a �` - t z ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Mant ca 823-7104 ❑ Tracy 836-6385 r Applicant - Return all copies to: Environmental Health Permit/Services 1601 E, Hazolton Ave., P.O. Box 2009, Stk., CA 95201 ,i FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO CASH] + EH 1EH 14.28 3-241REV,1/851 IAP [a� e �a ok, RO1-11..5