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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT R S 1601 E. HAZEL T ON AVE., STOCKTON, CA I' F1 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. 1�!i Job AddressW` City Lot Size PM �b Owner's Name �I Address Phone INI Contractors Address 3b License NolV!,0,;F6--7-- Phone ".� � TYPE OF WELL/PUMP: NEW WELL-{]- WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR Lf}� OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLD. _eROP-.,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 ' V-Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i f"7 Public ❑ Other f Delta "" Depth of Grout Seal_ Type of Grout _- 1 I I Irrigation _I11-Approx. Depth I 1 Eastern` Surface Seal Installed by _ " Repair Work Done Ty p of Pump f H.P. State Work Done Well Destruction ❑ Well Diameter / Sealing Material (top 50'1 Depih Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 1 I DESTRUCTION I i (No septic system permitted if public sewer is 1111 a available within 200 feetA r I Installation will serve: Residence_ Commercial_ Other M Number of living units: A Number of bedrooms x. 1 Character of soil to a depth of 3 feet: '� Water table depth 1 SEPTIC TANK ❑ Type/Mfg YCapacity No. Compartments PKG. TREATMENT PLT. ❑; 4� s ; s Method of Disposaat .: Distance to nearest: Well..- - —Foundation- Property Line j LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: : Well Foundation Property Line i SEEPAGE PITS I 1 Depth Size Number !6—'St7hl`IP =`-0,C] oistance to nearest: WeII Foundation Property Line DISPOSAL PONDS ❑ I� 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 Sah Joaquin Local Health District. Home owner or licensed-agen_t''.s signature_certifies_ttie 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-C-alifomis.'Contractors 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 'require inspections. Complete drawing on reverse side. t Signed X— -_ Title: Date:FOR DEPARTMENT USE ONLY J Application Accepted by Date ✓�� Area ` ! Pit or Grout Inspection by IM, Date Final Inspection by Date 2r3 v Additional Comments: I� ' ❑ Stk 466-6781 D 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 I. 5 FEE INFO CASH DUE AMOUNT REMiTTEO CASH RECEIVED BY DATE PERMIT'NO. ♦ EH13-24[REV.t4-28 •�'r/K 51 �• 2. � ! p IcTD-- �/ EH 1 •