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Q 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 " I (Complete in Triplicate) k Application shereby-made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is t made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for welUpump and the Rules and Regulations of the San Joaquin Local Health District. _ Job Address City Lot Size /2 S ,I PM " Owner's Name ` Address _ Phone : - �.. " Contractor ess License No, 'Phone TYPE'OF WELL/PUMP:, NEW WELL ❑ _ _ WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ' I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS"—t, i ED Industrial ❑ Open Bottom ElManteca Dia. of Well Excavation ' � 'R #` Dia. of Well Casing LJ Domestic/Private ❑ Gravel Pack ❑ Tracy Type ofCasing _t,��. ., -= Specifications [-i Public F] Other FlDelta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth i I Eastern SurlaceiSeal Installed by - Repair Work Done ❑ Type of Pump € H.P. State Work Done -, I Well Destruction ❑ Weil Diameter Sealing Material (top 501 �\\ Depth -L A f.Filler Material (Below 501 Y V TYPE OF SEPTIC WORK: NEW INSTALLATION (,I REPAm/ DDy�ION -�DESTRUCTI I o septic system permitted if public sewer is; +a ., /,lam/{ , vaiiable within 200 feet-) 1. 3 Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms ; P Character of soil to a depth of 3 feet: Water table depth " SEPTIC TANK ❑ ''Type/Mfg Ii Capacity No. Compartments f PKG.�:TREATMENT PLT. ❑ t . 1 — Method of Disposal Distance to nearest: Well Foundation Property Line ` s LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED' �❑ �Distance to.nearest: Well Foundation Property Line SEEPAGE PITS ['I Depth Size Number _•' SUMPS L- •Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ '' c f 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; a I f rulesand 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 shah not . employ any person in such'manner as toto 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 I`aws of California." t The applica t must call all requir inspections. Complete drawing on reverse side. Signed X Title: Date: I r ; PARTMENT USE ONLY Appiication Accepted by Date Z'I t Area - s �' ` 2 /1 a Pit or Grout Inspection by Date Final Inspection by Data I Additional Comments: CDStk 466-6781 ❑ Lodi 369-3621 ❑ Manteca i 823-7104 ❑ Tracy 835-6386 T } Applicant -.Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2409, Stk., CA 95201 .1.-„ _.. .. FEE.• --AMOUNT-DUE—AMOUNT-REMITTED CK `”` RECEIVED 8Y DATE t INFO CASH + EH t3-24IREV,1/ 51 Z'Ci ® -� ' ~� � � `� EH 16-28 s 6