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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 andlor 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. �+ `� 1 �/ .J City / !�-t Lot Size I i' — "' PM !J/Y Job Address I 11V IF "1I Y /�f� Address fes` �y Phone / Owner's Name LJ ` �-^ Contractor �` - Address "v` License No / Phone_ r 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 FI Public (=l Other R Delta Depth of Grout Seal Type of Grout--- I rout I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Y V Well Destruction ❑ Weil Diameter Sealing Material (top 501 ( ,I Depth Filler Material (Below 50') W TYPE OF SEPTIC WORK: NEW INSTALLATIO REPAIRIADDITION i 1 DESTRUCTION I I (No sbeti cyst m rmiilted if public sewer is Installation will serve: Residence_!ff'Commercial Oyhgf _ Number of living units: ?A 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 r Total lengthlsize FILTER BED ❑ Distance to nearest: Well Foundation Property Line i;. SEEPAGE PITS I I Depth —size fJ / �'' Number R SUMPS K -Distance to nearest: Well 0�00 '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 ordinances; state laws, and rules and regulations of the San Joaquin Local Health District. ," k%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 sulaject to workman's compensa- tion laws of California." ; The applicant must call for ail required inspections. Complete drawing on reverse side. Is t Signed X Title: !.-[J Date: F�ARTMENT USE ONLY Application Accepted by Date r � Area / Date Final Inspection by Date Pit or Grout Inspection by Additional Comments: ❑ Silk 466-6781 171 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 CK RECEIVED BY DATE PERMIT'ND. INFO +,EH 13-24 IREV,t/x sl �+ EH 14-2e