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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. 1331 / ' Jab Address 0� City a!�/ Lot Size pM Owner's Name Address W Phone Contractor's Name License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ti. PUMP INSTALLATION`'( SYSTEM REPAI ?<DISPOSAL, OTHER 11DISTANCE TO NEAREST: SEPTIC'TANK : = -SEWER LINES- 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 l�1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications (i _ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout LJ\! ❑ Irrigation —Approx. Depth 0 Eastern Surface Seal Installed by Repair Work Done ❑ Type of PumR H.P. 1 State Work Done V, Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Materia! (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 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 Lime SEEPAGE PITS ❑ Depth Size Number �,. 'SUMPS� Foundation -Property'Linei� -- ��---=-�-R-- ' �--= DISPOSAL PONDS 71 I hereby certify.that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state Jaws, 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 t 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 sub'ect to workman's compensa- tion laws of California." ' tjcdohe The applicant m c I for I requ' d ins�nsc' drawing on neve s Signed Title: R DEPARTiAENT USE ONLY ) ^^�� a. r-t Application Accepted by { / Z"G� _ Date Area;�-'s o J Pit or Grout Inspection by Date mal Inspection b _ Date Additional Comments: ❑ Stk 466-Ml ❑ Lodi -369-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 Applicant- Return all. . copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA�95201 "-1,_ FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE' PERMIT NO. )NFO ' CASH + EH 13 [REV.101931 1 EH 1426 -� f ;ate