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APPLICATION FOR PERMIT • s c 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 heteby 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 City lot Size X PM 1 �,Owner's Name i�/ ZWdress Phone Contractor99K Address Lice hon TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 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 171 Public 11 Other F1 Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. 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 Filler Material (Below 50') ' TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION (No septic system permitted if public sewer is vailable within 200 feet.) t r 4 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 Capacity No. Compartments TREATMENT PLT. ❑ Method of Disposal b ;.. 4tr Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER.BED" ❑ DistannCMT&nearest: Well .Foundation Property Line SEEPAGE PITS 11• Depth Size Number ' SUMP'S: ❑ Distance to nearest: Well _ Foundation Property Line vka. DISPOSAL PONDS' ❑ sir1 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 andregulations 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 com ensa- "'. ',. g fY Pe P P Y P 1 P tion laws of California." The applicantust call for all required inspec ns. Complete drawing on reverse side. Signed Title: 0� -� Date: FOR DEPARTMENT USE ONLY Application Accepted by _� L_ Date `Z� ea Pit or Grout Inspection by Date?? Final Inspection by �L ' t` Additional Comments: J i Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 E. 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 [AMOUNT DUE AMOUNT REMITTED CK C RECEIVED BY DATE PERMIT"NO. t.EH 13-24(REV.tin 5) - EH 14-29