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APPLICATION..FOR PERMIT SAN JOAQUIN;LOCAL HEALTH DISTRICT �N Q W 1601 E. HAZEL T Ofd .AVE., STOCKTON, CA H "-Telephone (209) 466-6781 ND PERMIT EXPIRES 1 YEAR FROM.DATE ISSUE (Complete in rTriplicate) .,5 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work Aerein described. This application is made in compliance with Sari`: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 Lot Size PM Owner's Name .Aad ress Phone Contractor !Ip Address NLicense No. Phone 1 TYPE OF WELL/PUM : �I NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ a OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS it INTENDED USE ,TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑'Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private El Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation LApprox. Depth.-. ❑ Eastern Surface Seal Installed by a. Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Seating Material (top 561 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑- REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is available within 200 feet,h Installation will serve: Residence_ Commercial Other Number of living units: .11. Number of bedrooms f f Character of soil to a depth of 3 feet: Water table depth �r SEPTIC TANK ❑ Type/Mfg j Capacity No. Compartments, PKG. TREATMENT PLT. O Method of Disposal f I Distance to nearest: Well Foundation SProperty Line LEACHING LINE ❑ No. & Length of lines Tota! length/size— FILTER BED ❑ i Distance to nearest: Well Foundation Property Line I l l f SEEPAGE PITS ❑ Depth Size ' 4 Number SUMPS ❑ Distance to nearest:- Well 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 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."r + The applicant must cal! for all required inspections. Complete drawing on reverse side. ! Signed XAe ca Title: _ Date: FO 'DEPARTMENT USE ONLY [�'�] Application Accepted by `�� a' ^ Date —g ( Area © '/ Pit or Grout Inspection by Date Final Inspection y r _ Date Y Additional Comments: �`�`I�� :,�;,.�L1� _,g_ c. �q ❑ Stk 466-6781 ❑ Lodi 369-3621 Manteca .823-7104 ❑ Tracy 835-6385 f Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 :I I tFEE , INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. + EH126 1, EH 1428 REV,t/R5 -7Y A� � ©O /J � C� 11 ' --11 ,