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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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 Address ff6/C2 City �t/' `�'� Lot Size \M! �dd `PM Owner's Name-m" r Address Contractor Li A Address License No. Phone TYPE OF WELL/PU NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION LJ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWE47UF DISPOSAL FLD. PROP. LINE FOUNDATION AGRICE WELLOTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL OBLE REA CONSTRUCTION SPECIFICATIONS LJ Industrial ❑ Open Bottom C3eca Dia. of Well Excavation Dia. of Well Casing El Domestic/Private ElGravel Pack IDrac Type of Casing Specifications ❑ Public 1-1Other Delta Depth of Grout Seal Type of Grout I I Irrigation --Approx. Depth I 1 Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H,P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50') Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION i I DESTRUCTION il\lo septic system permitted it public sewer 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 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 0Z5 SEEPAGE PITS I 1 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 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 applicant must call for all required inspections. Complete drawing on reverse side. Signed X-5Wtc /✓ ` ✓ �]Title: � P��-�/t l Data: FOR DEPARTMENT USE ONLY r Application Accepted by Date �� Z Area a Pit or Grout Inspection by Date Final Inspection by Date r Additional Comments: ❑ Silk Lo 466-6781 ❑ di 3621 ❑ Manteca 823-7104 ❑ racy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 (NFD AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PER.yMIT'NO. + EH 1 C 14-2a 3-24(HEV EW .5/Hh) 1r� / �J Cl�