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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T O.N AVE., STOCKTON, CA l Telephone (209) 466-6781 � �n PERMIT EXPIRES r1 YEAR"FROM DATE ISSUED (Complete in Triplicate) a Application is heieby 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 Regulation&of the San Joaquin Local Health District.`�' ' 4 Job Address City Lot Size ,SU x�� PM, Owner's Nameddress Phone Contractor Address License No. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ Phone DESTRUCTION Ll PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMP S INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION_ ON 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 f Type of Grout LJ Irrigation _Approx.IDepth ❑ Eastern¢,,,,,._Surface Seal Installed by Repair Work bone ❑ Type of Pump H.P. State Work bone Well Destruction ❑ Well Diameter -Sealing Material Itop 50') 4 ' Depth Filler Material o(9416w"50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION IJ` DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence i Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:,IWater table depth SEPTIC TANK X Type/Mfg Capacity No. Compartments PKG. TREATMENT"PLT. ❑ Method of Disposal Distance t nearest: Well Foundation Property Line rR LEACHING LINE ❑ No. & Length of linesr FILTER BED Total length/size ❑.- Distance to nearest: Well ' r Foundation Property Line 'SEEPAGE PITS ❑ Depth 4R `' "i SizeSUMPS Number y r 1 . l a ❑ Distance to nearest"'---Well } 6F undation Property Line DISPOSAL PONDS ❑ C., I hereby certify that I have prepared this application and that the work will bedone in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District.!: j 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: 1 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." y The applicant must call lffor all required inspections. Complete drawing on.reverse side. Signed �c�rr `� c��+ Title: , Date: r� m. FOR DEPARTMENT USE ONLY Application Accepted byDate ~ Q� Area Pit or Grout Inspection Date _ Final Inspection by - . J Date 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 AMOUNT DUE: !!� AMOUNT REMITTED INFO r �} RECEIVED BY DATE PERMIT'NO. + EH 1324 1REV,1/d 51 1' r EH-14-28 r