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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON 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 Addresst� AA City �iQif Lot Size PM Address C� , 17-a City Contractor's Nam License No. ao� ��—� _ 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 ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta 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 Material Itop 50'1 Depth Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ commercial_ Other y Number of living units:__...� Number of bedrooms , Character of soil to a depth °f 3.feet: Water table depth o SEPTIC TANK f� Type/Mfg eh� rJ�Lru cam, Capacity aC'o No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well 50Foundation -�.�a` Property Line LEACHING LfNE No. & Length of lines f Vkt Total length/size b Y FILTER BED ❑ Distance to nearest: Well_Foundation l Property Line r SEEPAGE PITS Depth �/f Size a� ° Number .3 SUMPS Distance to nearest: Well A126 Ll— Foundation� r Property Line DISPOSAL PONDS ❑ I 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 fallowing: "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 applica must cal or all r ired inspections. Complete drawing on reverse side. Signed Title: �� Data: JQ Z4y F R DEPARTMENT USE ONLY r� Application Accepted by Date w Area , r 6-t Grout Inspection by Date Final Inspection by Daten 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.Q. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. + EH 14-261REY.10/831