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APPLICATION.FOR PERMIT SAN JOAO.UIN LOCAL#HEALTH DISTRICT 1601 E. HAZELTON AVE.,•STOCKTON, CA MC) 4\4 Telephone (209) 466-6781 j PERMIT EXPIRES 1 YEAR FROM DATE ISSUED n (Complete in,Triplicate) If'.#•" . r; 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 welllpump and the Rules and Regulations of the San Joaquin Local Health District. r �d City Lot Size PM Job Address - - "Address Phone i Owner's Namegf � Contractor _ Address License No. Phone TYPE OF WELL/ MP: F F NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION F1SYSTEM REPAIR 11OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK, SEWER LINES DISPOSAL FLO.I PROP. LINE FOUNDATIONk AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE ,.TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �.� Dia. of Well Casing ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Type of CasingSpecifications ❑ Domestic/Private El Gravel Pack El Tracy Yp , ! i] Other " `"""❑"Delta — ——Depth of Grout Seal ; Type of Grout �] Public ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by v' Repair Work Done ❑ Type of Pump = H.P. State Work Done _ Well-Destruction ❑ Well Diameter Sealing Material (top 50') J Depth Filler Materia! (Below 50) k TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIONINo septic system permitted if public sewer is 41 ` available within 200 feet.I f Installation will serve: Residence Commercial— Other Ik 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. (J Method of Disposal j • Distance to nearest: WellFoundation Property Line ' f LEACHING LINE------->=� No. & Length of lines ice` Total lengthlsize" 1 ' FILTER"BED ❑ Distance to nearest: Well 'x Foundation Property Line Q - M 1r' RSI 5 SEEPAGE PITS ❑ Depth Size ' Number SUMPS "` 10'�'�Distance to nearest: Well Foundation Property Line DISPOSAL PONDS i ❑'"` k = ill be done in accordance with San Joaquin county ordinances, state laws, and I hereby certify that I have prepared this application and that the work w 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." The applicant must call for all required inspections. Complete drawing on reverse side. Date: Signed X Title: ' FOR DEPARTMENT USE ONLY Application Accepted by 1 \i Date Area Pit or Grout Inspection y Date Final Inspection b Date Additional Comments: EDStk 466-6781 ❑ Lodi 369-3621 Ll Manteca 823-7104- i r EI Tracy 635-6385 k Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2409,Stk.; CA 95201 r s I FEE AMOUNT DUE AMOUNT REMITTED CASH f RECEIVED BY' jCPERMIT NO. INFO t + EH 13-2.4(REV.-�i x 51 - 226 'l C>9 n i