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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 / / —6) To K iAj C u L U w i City Lot Size PM Owner's Name 1� E�� Address Phone Contractor Address "iLAD L_ License No. C hone TYPE OF WELL/PUMP: NEW WELL [I WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR U 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 \ Ll Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F] Public ❑ Other Fl Delta Depth of Grout Seal Type of Grout _ I I Irrigation .Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done U Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') _ TYPE OF SEPTIC WORK: NEW INSTALLATION AIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial__ Other fi Number of living units: Number of bedrooms _ Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK EL--Type/mfg Capacity_AM No. Compartments PCG. TREATMENT PLT. ❑ Disposal Method of D�isp� � Distance to nearest: Well �� Foundation Property Line LEACHING LINE CHr�_No. & Length of lines Total length/size FILTER BED 1U,-Cristance to nearest: Well.�_ _ FoundationsProperty Line C SEEPAGE PITS f--- Gepth �- Size____32> _ Number SUMPS Ll Distance to nearest: Well -1 Foundation 62,_ Property Line DISPOSAL PONDS ❑ 1 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 c Mies 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 la f Califorb.*.The applica t u ll r uire I spe tete drawing on reverse side. Signe - Title: } � LG� Date: at FOR DEPARTMENT USE ONLY ^ t Application Accepted by V' t` Dater it or Grout Inspection by D to Date Additional p y �� S ?f GC" %f— inal Inspection b � Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ 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 INFO CASH DATE a J PERMIT�N101. EH 3-241REQQ�EH 14-2e � i� 6f