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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 ti_ , - PERMIT EXPIRES 1 YEAR 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. Igr q0 Job Address } drA City _!4:f:Lot Siz---------- - - - Owner's Nam i`'• Address Phone Contractor's Name - License No i TYPE OF WELL/PUMP: Phone NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER .LINES _ DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER_ WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial I ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/ Private > Cl Gravel Pack ❑ Tracy Type of Casin {s YR g . Specifications i ❑ Public ❑ Other _ 71Delta Depth of Grout Seal I Type of Grout El Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H. P. �'State Work Done Well Destruction ❑ Well: Diameter Sealing Material (top 501 f , Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION -_ DESTRUCTION -7 {No septic'system-permit 5 h available within 200 feet. Installation will serve: idence _%Commercial — Other ! ' r i 1 Number of living. units: Number.o be ro s�-CaDacitv_/--Y Character of soil .to a depth of 3 feet: e -Water table depthSEPTIC TANK ❑ Type/Mfg No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest:. Well Foundation Property Line LEACHING LINE FILTER BED ❑ No. & Length of lines. - Total length/size Distance to nearest: r Well Foundation Property Line SEEPAGE PITSX Depth 4L Size Number - SUMPS ❑ Distance to nearest: Well Foundation A' Property Line DISPOSAL PONDS ❑ �., 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, and rules and regulations of the San Joaquin Local Health District. 1_Y r Home owner or licensed agent's signature certifies the following: "I certify that in -the performance -of the work for which this p [mit 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: '9'cartify that in the performance of the work for which this -permit is issued, -I -shall employ persons subiect to workman's compensa- tion laws of California." ,�. The app 'can s all f r r re inspecti n,. mplete'drawing o r ' erse side. /G Signed r Title: Date j FOR DEPARTMENT USE ONLY - Application Accepted by { Date Area Pit or Grout Inspection by Date Final Inspection by _ _ Date Additional Comments: f �� Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835=6385'- -_.- _ ... • . - App icant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 if public sewer is + EH 13.24 iREV, EH 1126 n O N rh