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j APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE.T ON AVE., STOCKTON, CA { Telephone (209) 466-6781 PERMIT EXPIRES 'I 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. I Job Address �'" ' City Lot Si le PM Owner's Name • . ` Address Phone -01 Contractor Address lie ansa No. Phone I TYPE OF WELLIPUMP: EW WELL ❑ WELL REPLACEMENT ❑ DESTRUT ION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL j PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation w Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1-1 Public ❑ Other Ci Delta Depth of Grout Seal Type of Grout _-. I I Irrigation _ Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done 0 Type of Pump H.P. State Work Done Ip� Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION W REPAIR/ADDITION I I DESTRUCTION i I (No septic syslem permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial`��Other�� / / !� ,/'� � Number of living units: t Number bedrooms I�[� yrs Character Of soil to a depth of 3 feet: Wateri table depth 1- SEPTIC TANK ❑ Type/Mfg G� Capacity my: No. Ci mpartments PKG. TREATMENT PLT. ❑ t Method of Disposal Distance to nearest: Well Foundation L Property Lin 1 LEACHING LINE ❑ No. & Length of lines ..yt iTotal length/size FILTER BED ❑ Distance to nearest: Well3� Foundation afti Property Line I SEEPAGE PITS I I Depth Size Number SUMPS L7 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ II 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 4p. nce of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws o California." The app) ant ust c I for PI)jrC late drawing o v rse side. Signed Title: Date: 16 < 3 OR PLPARTMENT USE ONLY Application Accepted by Date a Area II Pit or Grout Inspection by bate Final Inspection by Date I Additional Comments: E�2 ❑ 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 MOUNT DUE AMOUNT REMITTED CASH RECEIVED BY GATE PERMIT NO. h kNF 4 3__ ` ,, /" /� +.EH 13-24IREV.i/H5) . Il ,t1 rJ.�1 3'�'li q0 C/V—57 I EH 14-26 LJ v Cl