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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. s - 1 r © City, Lot Size S U PM Job Address Phone Owner's Name r`� Contractor L, h �,� Address SO License No. JQs Phone S TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR Cl OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i pia. of Well Casing ❑ Industrial ❑ Open Bottom ❑ Manteca Ria. of Well Excavation Type e of Casing Specifications ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy yp g Type of Grout - FI Public R Other Ll Delta Depth of Grout Seal I Irrigation Approx. Depth---.•d.l-Eastern.�.+.-•-wSurface-Seal-Installed-by-- - Repair Work Done 11 `Type of Pump t H.P. State Work Done t Well Destruction ❑ Well Diameter Sealing Material (top 50') F ! \ Depth '- Filler Material (Below 50') i TYPE 01= SEPTIC WORK: ' NEW INSTALLATION I ] REPAIR/ADDITION l I DESTRUCTION [ septic system permitted if public sewer is .�._ t available within 200 feet.) �v1 Installation will serve: Residence_!i__�Commercial— Other 1 Number of living units: Number of bedrooms -- Character of sail to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg _ - Capacity No. Compartments r CI Method of Disposal PKG. TREATMENT PLT. Distance to nearest: Well Foundation Property Line (' LEACHING LINE ❑ No. & Length off Total length/size lines \ FILTER BED ❑ Distance to nearest: Well Foundation Property Line— Number SEEPAGE PITS I l Depth t Size z SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ - + I hereby certify that I have prepared this application and that the work will,be don in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. I H e owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shalt not amp ny person in such manner as to become subject to workman's compensation laws of California." (contractor's hiring or sub-contracting signature certifies t olkowing:' rt that in the performance of the work for which this permit is issued,I shall ey persons subject to workman's compensa- a^ t tion laws of 'fornia.' T e applicant u tail f all equ C mp t drawing on ' arse si _ ,.. Signe Title:� Date: k FOR DEPARTMENT USE ONLY { Date Area — Application Accepted by �•-^-�•^"" """""" � „� pate Pit or Grout Inspection by pace Final inspection by ..5 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621,, ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environm�tal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 .Q. .�--- -_ --- ^ FEE• AMOUNT DUE;�',..:`AMOUNTREMITTED CASHRECEIVED BY' �- DATE r PERMIT'NO. +.EH 13-24(REV.I/K 51INFO ' EH 1 4-2e