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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I 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 _ ,09 • CC City —�� Lot Size PM Owner's Name Address Cil//� Phone f f �1 C' Contractor's Name 7 License No. 31 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 J+ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r a INTENDED USE TYPE: OF WELL . _'`PROBLEM AREA CONSTRUCTION SPECIFICATIONS v ❑ industrial ❑IOpen Bottom' _C] Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack'�. ❑,Tracy Type of Casing - Specifications " ❑ Public Ll Other fII Deltas Depth of Grout Seal _- Type of Grout ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump' H.P. State Work Done Well Destruction,.- ❑ Well Diameter Sealing Materia! {top 50'} { Depths` Filler Material (Below W1 n TYPE OF SEPTIC WORD NEW-INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is T available within 200 feet.) .r Installation will serve. Residence, Commercial Other th Number of vi'ng units:_/_ ,.Number of bedrooms Character of soil to a depth of 3 feet: • r�fi _ Water table depth 0 SEPTIC TANK ❑ `Type/Mfg Capacity No. Compartments PKG.`TREATMENT PLT. ❑ Method ofrDisposal f f Distance to nearest: Well Foundation Property Line eU ACHING-LINEI- No. & Length of lines A 2!9-'Y&'A1 Total length/sizer .* FILTER BED ❑ Distance to nearest: Well,/C3O ,Foundation Property Line w SEEPAGE PITS o Depth Size _ Number SUMPS ❑ Distance to nearest: Well 11�15 t-1) Foundation Property Line Z40 DISPOSAL PONDS ❑ 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. r 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." Contractors 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 Californ' . The applicant must cfor I requi inspections, -drawing-on`reverse side. l_ Signed Title: Date: FOR DEPARTMENTUSEONLY Application Accepted by Date Area 7 Pit or Grout Inspection by - Dated" � Final Inspection by �' Date`s 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 AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`NO. + EH 13-24(REV.10183) EH 14-28 O'1