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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 % Cit Lot Size PM�•' Owner's Name ass Phone �,��' X &Z � d Contractor` Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REP'ACEMENT ❑ DESTRUCTION PUMP INSTALLATION LI SYSTEM REPAIR 17 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL 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 F] Public ❑ Other F Delta Y Depth of Grout Seal Type of Grout _ I I Irrigation —Approxi Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H,P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') ~ Depth I Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION IJ DESTRUCTION l I (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 4i_Capacity""'" No. Compartments F PKG. TREATMENT PLT. ❑ I . .f Method of Disposal . Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 4 SEEPAGE PITS I I Depth I Size Number SUMPS Ll Distance!to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ f 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 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 m t call for all required ' ction pl drawing an raver side. Signed X Title: r Date: " 46 OF ,^FyOR DEP HENT USE ONLY Application Accepted by AA •� �9A �(1111\� _____ Data S� �`� Area 3 i Pit or Grout Inspection by Date Final Inspection by Dater Additional Comments 41 ,Q ❑ Stk 466-6781 ❑ Lodi 3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant.- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton.Ave., P.O. Box 2009, Silk., CA 95201 F I INFO FEE AMOUNT DUE I AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. r EH 13-24(REV. 5) '2>S-UU `�•��'�ff b Z[„ C..r} ��,2cm EH 14-29