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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1YEAR 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. Job Address City Z�Lot Size PM Owner's Name Address _ Phone J-&Contractor �' Address i+ (cense N0.616e Phone_ _ _. . _ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. - PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS .INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' ❑ Industrial ❑ Open Bottom O-Manteca, __Dia.,ofwWell_Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications �! l"I Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation _.-Approx. Depth ' l 1 Eastern Surface Seal installed by Q Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 } a Depth a Filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIWADDITION l 1 DESTRUCTION (No septic system permitted if public sewer is %available within 200 feet.) + Installation will serve: Residence_ Commercial_ Others' Number of living.units: ',Number'of bedrooms s Character of soil to a depth of 3 feet: r �' Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ . Method of Disposal Distance to nearest: Well Foundation Property.Line r LEACHING LINE ❑ No. &,;Length of lines Total length/size FILTER BED ❑ Distance to r earest: Well Foundation Property tine SEEPAGE PITS I I Depthr Size Number SUMPS LI Distance to nearest: Well Foundation Property Line i DISPOSAL. PONDS ❑ t ) i 4 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 r rules and regulations of the San Joaquin Local Health Diltrict. , .. 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 Califorhia." 1 The applicant m call for all required inspections. Complete drawing on reverse side. F Signed X Title: Date: 'A� UCS � s FOR DEPARTMENT USE ONLY 1 { Application Accepted by A A Date �E '21- A ea f I ti ti Pit'or Grout Inspection by Date Final Inspection by ., Date /O rG Additional Comments- 0 omments ❑ Stk 466-6781 ❑ Lodi 3693621 ❑ 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 95201CKO FEE INFO AMOUNT-DUE' '"AMOUNT REMITTED--/ CASH RECEIVED BY pAtE,' PERMiT"NO. 1 +.EH 13-24'(REV. i e 5) - - EH 14-26' �ko 1 'ti.