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I ,I T APPLICATION FOR PERMIT 4 re I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAMILTON AVE., STOCKTON, CA Telephone.1209) 466-67'81 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Hoalth District for a permit to construct and/or install the work herein descr7oad.This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No.1862 for weg/pump and the Ruins and Regulations of the San Joaquin Local Health District. f Job Address —. f � City Lot Size PM Owner's Name Ir Address Contractor COWQW, Address �+ License No. Phone IQZ� t TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT _ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ xOTTH_ER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO.��PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICA I ;1 {� ❑ Industrial ❑Open Bottom ❑ Manteca Dia.of Well Cava h ► Dia.Of Well Casing ' omestic/Private Gravel Pack racy Type If of Cas{ExSpecifications IPS ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout f.] Irrigation ---Approx. Depth ❑ Easter Surface Seal Installed by `0f= Repair Work Done C3 Type of Pump H.P. State Work Done a Well Destruction ❑ Well Diameter Sealing Material{top 150 O Depth Filler Material(Below ST) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION L1 DESTRUCTION❑ (No septic system permitted if public sewer is available within 2013 feet.) Installation will serve: Residence— Commercial_ Other !dumber of Irving 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.Q Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No, &length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Una i SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ 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 agenfa 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 Callforrila."Contractor's hiring or sub-contracting signature certifies the following:"1 certify that in the performance of the work for which this permit is lowed,I shall employ persons subject to workman's componsa- tlon laws of California." Theapplican u call f r all q {rad inspections. Complete drawing on r eme_sidDe. i Signed Title: f�1--. Date: — 1-7i F EPA NT USE ONLY Application Accepted by �— IF�lnal Date ��` 8-f Area Pk or ro Inspection by� Dste inspection by Date Additional Comments: — 42� / ❑Sik 468.8781 ❑ Lodi 369.3621 ❑ Manteca M7104 ❑Tracy 83543385 Applicant-Return all coples to: Environmental Health Permit/Sarvices 1601 E. Hazeftan Ave., P.O. Box 2009,Stk.,CA 9=1 I NFO FeE AMOUNT DUE AMOUNT REMITTED CK RECEIVED I3Y DATE PERMIT'NO. + EH 1344(REV.ile7) EH 14-26 `