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I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT S I 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED k (Complete in Triplicate) Application is heieby 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 Na- 1862 for wail/pump and the Rules and Regulations of the San Joaquin Local Health District. n i Lot Size PM Job Address City S , Address �� k Phone Owner's Namep. f E� E ` s ContractorLicense No Phone : .Addressor-. - - -�� TYPE OF WEL11PUMP: NEW WELL ❑_ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ iI SYSTEM REPAIR ElOTHER ❑ f t DISTANCE TO NEAREST: SEPTIC TANK SEWE LINES DISPOSAL FLD. _PROP- LINE g FOUNDATION AGRIC LTUR WELL OTHER WELL - PITS/SUMPS INTENDEDUSE TYPE OF WELL PROBLEM ARE CONSTRUCTION SPECIFICATIONS ❑ industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications j fl Public `Other Cl`I7elta "�`"Depth"of-Gfout-Seal"` ""y"""" `'Type of Grout—.-- ;,—r7 111 I I Irrigation -_,.Approx. Depth l I East n Surface Seal Installed by - ' Repair Work Done ❑' Type of Pump H.P. State Work Done Well Destruction ❑; Well Diameter Sealing Material (top 50') I Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITI N I PJE&TRU TION INo septic system pe milted if ublic sewer is available within 200 et.) Ins tallationwill serve Residence_ Commercial_--_0th e'r� Number of living units: Number of bedrooms Character of soil to ardepth of 3 feet: Water table depth s � SEPTIC TANK L1Type/Mfg Capacity No. Compartments PKG: TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line ► To. lal . lengh _ LEACHING LINE lines t ..r,.,a.....,.�...�.-..,..rte,.- -.,�.--•�,...-T-....°-- r--•- -- t�-a L - FILTER BED ❑ Distance to nearest: Well Foundation Property Line f t 1 SEEPAGE PITS I I Depth Size 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 taws, and rules and regulations of the San Joaquin Local Health Di$trict. f 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." Contractors 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 applica must call all requir inspections. Complete drawing on reverse side. 1� z � �� - Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date +� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-11385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY �/j DATE PERMI]T'NpO..q INFO 'L �l�lF{ +.EH 13-24 IREV.t/K 5) � + EH 14-26