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E I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1641 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. r Job Address LCity �/$�EG' Lot Size,-/0 PM } Owner's Name LC Address �' h� Phone Contractor's Name License No. Phone �+ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION I� SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE N FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS p4 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing .E'66rinestic/Private Eff'Gravel Pack El /� Tracy Type of Casing PC y Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Vace Seal Installed by r- Repair Work Done ❑ Type of Pump Sa .4, H.P. i Z State Work Done V) Well Destruction ❑ Well Diameter Sealing Material (top 501 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 Number of living units: Number of bedrooms t 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 � SEEPAGE PITS ❑ Depth Size Number] SUMPS ❑ Distance to nearest: Well Foundation 'Property Line DISPOSAL PONDS ❑ 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." +` I The applicant mu for all quire tions plate drawing on reverse side. / Sign Title: �` ` Date: FOR DEPARTMENT USE ONLY Application Accepted by +� Date Area f cry-- Pit or Grout Inspection by Date Final Inspection }by ' Date 3-?c!-T� Additional Comments:, ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 i Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 4 ( , FEE AMOUNT DUE AMOUNT REMITTED CK* RECEIVED BY DATE PERMIT NO. INFO CASH +EH 13-24 1REV. 10183) "l 5 00 EH 1126