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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 correww 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. l ^T/ _ L® Job Address f7y Al �� City-a(✓�C� Lot Size PM t Address 121) �R¢ 1 Owner's Name ne e Contractor rens a _PW,, License No. C s_J phone Q v ^ n TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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 Cl Open Bottom ❑ Mantece Dia. of Well Excavation Dia, of Well Casing Q ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ClT '�- Pa Type of Pump H.P. State Wwk Done Wall Destruction ❑ Well Diameter Sealing Material(top 50'1 �- Depth Filler Mat erial (B low 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITIO DESTRUCTION ❑ (No septic system permitted if public sewer is • Installation will serve: Residence Commercial Other available within 200 feet.l Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Er No- &Length of lures C Idd Total length/size- FILTER BED MV Distance to nearest: Well Fou ion 2 Property Line Vs� 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 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 maturer as to become subject to workman's compensation laws of California."Contractor's hiring or sub-ccntracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued,I stall employ persons subject to workman's compensa- tion laws of California." The appli must Cell f7reouiod insp rods. Complete drawing on reverse side. Signed Title: ( % Date: /f/FOR DEPARTMENT USE ONLY _ Application Accepted by t r4 Date Area_ Pit or Grout Inspection by Date Final Inspection by I t, Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 3 3621 ❑ Manteca 823-7104 ❑Tracy • Applicant- Return all copies to: Emrironmental Health Penh/Services 1601 E Hazelton Ave., P.O. Box 2008, Stk.. CA 952DI FEE INFO AMOUNT WE AMOUNT REMITTED CASH RECEIVED BY DATE PER NO. ♦EH 1121(REV.1/a5) '7o Op 5/IL� py �_L�b