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APPLICATION FOR PERMIT . i ' SAN JOAQUIN LOCAL HEALTH DISTRICT f1601 E. HAZELTON AVE., STOCKTON,.CA r Telephone (209) 466-6781 t . PERMIT EXPIRES 1 YEAR FROM DATE ISSUED dl ,� (Complete in Triplicate) Application is hereby made to the San Joaquin Local Heahh District for a permit to construct and/or install the work herein described.This application i t 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 �]I Local Heaith District. � � Job Address y City !`— Lot Size PM M Owner's Name ~ Address ��` Phone ++a� Contractor's Name License No. r Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELt REPLACEMENT ❑ DESTRUCTION ❑ ' PUMP INSTALLATION SYSTEM ftEPAJR Ci OTHER ❑ —U F DISTANCE TO NEAREST: SEPTIC TANK 1 SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA SCONSTRUCTION SPECIFICATIONS ❑ Industrial Ll Open Bottom E Manteca 1` 'pia. of Well Excavation Die. of Well Casing X Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications :1 Public ❑ Otherf ❑ Delta Depth of Grout Seal Type of Grout ❑ irrigation --Approxi Depth ❑ Eastern Surf a Seal Installed by Repair Work Done 7 Type of Pump H.P.` 1 �- State Work Done ? Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth 1 Filler Material (Below 5(Y) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION-0 iNo septic system permitted if public sevLer is available within 200 feet.) 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 4 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG.TREATMENT PLT.❑ Method-of Disposal Distance to nearest: Well —Foundation - -ProperN Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED Cl Distanc ' nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth -a-Size= Number i I 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 or&narxizs, state laws,and 4 rules and regulations of the San Joaquin Local Health District. i Home owner or licensed agents 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 k certifies the following:"I certify that in the performance of the work fpr which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." The applicant,rtlust cal for all reuired irS�pe t ns. Complete drawirig on revue side. F Signed �F1T.r 4 r {y� Tide: f L �• Date: L R DEPARTMENT USE ONLY � , i-� Application Accepted by Date 2" -) Area QQ Ph or Grout Inspection by Date Fina Inspection bye /2j �'"`Aate Additional Comments: A ❑ Stk 466-8781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazehon Ave., P.O. Box 2009, Stk., CA 95201 INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. t EH EH 13-24 �(REV.101631 J