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APPLICATION FOR PERMIT S " SAN JOAQUIN LOCAL HEALTH DISTRICT ` 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PAYML!VT PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Receive (Complete in Triplicate) �C�, 1 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein ZIEW. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump annd Regulations of the San Joaquin Local Health District. " "MENTAL HEALTH ISERVI�ES Job Address City Lot Size PM Owner's Name Address Phone Contractor 4mwAddress Jicense No. .. 1 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ;* DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATIONAGRICULTURE WELL OTHER WELL PITS/SUMPS I 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well'Excavation Dia. of Well Casing Domestic/Private 171 Gravel Pack,,�„.„4❑Tracy_.„ , Ty* pe.of_Casing ._ "" '` Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal �� Type—of Grout""`""" I' ❑ Iry€gation _.--Approx. Depth ❑ Eastern Surface Seal Installed by 1� I Repair Work Done f Type of Pump H.P. State Work Done Age-AMC qfte"u Well Destruction ❑ Well Diameter i Sealing Material {top 501 _� _� 2> W DepthJ Filler Material [Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ,DESTRUCTION ❑ [No septic system permitted if public sewer is ' available within 200 feet.] Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms Fj Character of soil to a depth of 3 feet: I ! Water table depth SEPTIC TANk__4 ❑ Type/Mfg ` j Capacity No. Compartments PKG. TREATMENT PLT. ❑ 4 'Is Method of Disposal i Distance to nearest: Well 4Foundation Property Line LEACHING LINE ❑ No. & Length of lines i F "T - Total length/size FILTER BED ❑ Distance to nearest: Well I Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ElDistance to nearest: Wew I `"Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that'thework will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District.'- I 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 wprkman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the-'W,4 ork for r which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." The applic�rnust�caf requir�inspec�tions. omplete drawing vn re arse side. �o�Signed Title: Date: , I FOR DEPARTMENT USE ONLY 7. Application Accepted by Date / L' Area Pit or Grout Inspection by Date 4Z nal Inspection by Date I Additional Comments: ❑ Stk 466-6781 ❑ 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 INFO .AMOUNT DUE AMOUNT REMITTED CASH RECEIVED RECEIVED BY DATE PERMIT'NO.' 4 EH 18-24(REV.1/6 5) y 2 G /�� [h _ /y� EH 14.28 i