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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 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 1 City Lot Size PM Owner's Name4r_- � JD4/L Address Phone Contractor Address / AazLicense No. Phone 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. ❑ Open Bottom , El Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack r ❑ Tracy - - Type of Casing Specifications ('1 Public n Other 11 gelta - Depth of Grout Seal Type of;Grout . I I Irrigation .-Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done L] Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Dia r Sealing Material (top 501 Filer Material (Below 501 �4 ` TYPE OF SEPTIC WORK: NEW INSTALLATION R/ADDITION I I DESTRUCTION 4,QNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Resi a ce_ Commercial ther 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 PKG. TREATMENT PLT.❑ Method of Dispopal Distance to nearest: Well Foundation_2A Property Line Sd dV LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well_16() _ Foundation 71-D _ Property Line SEEPAGE PITS I I Depth 2 r' Size Number SUMPS Cl Distance to nearest: Well Foundation A 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 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.4jequired inspections. Complete drawing on reverse side. 3- 2/—A j Signed X- J Title: (�r/Yt�i r Date: - 2/^ FOR DEPARTMENT USE ONLY 2 ` Q Application Accepted byA\aL Date J �1� �C/J Area Pit or Grout Inspection y Date Final Inspection by��. C��x l— � Date 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 INFO —AyMOUNT DUE AMOUNT REMITTED CK 9 CASH RECEIVED BY DATE /PPEER.,MIVNO. i EH124'IREV.rin5r 4. EH 14.28