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f APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED' s " V R (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 Ryles and Regulations of the San Joaquin .r"Local Health District. Job Address / ,` City Loi Size PM 4Owner's Name" Address Phone } Contractor Address License No. o- Phone r TYPE OF WELL/PU P: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION'Ll SYSTEM REPAIR El OTHER -❑ 4 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION A AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t ° ❑ Industrial ❑ Open Bottom E] Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ' FD Public t. ❑ Other k ❑ Delta Depth of Grout Seal Type of Grout a.i ❑ Irrl`gation. ' .. ---Approx. Depth ❑ Eastern Surface Seal Installed by _ Repair'Work Done ❑ Type of Pump H.P. State Work Done } Well Destruction SISAE] ,,,.•Well.Diameter._ Sealing Material (top 50') # Depth FillersMaterial (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) y Installation will serve: Residence_ Commercial— Other Number of-living.units: Number of bedrooms Character of soil to at depth of 3 feet: Water table depth SEPTIC.TAN_K x ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal 1� ; G Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size a "FILTER BED i ❑ Distance to nearest: Well Foundation Property Line ' I 4SEEPAGE PITS ❑ Depth Size Number ;SUMPS ❑ Distance to nearest: Well Foundation Property Line ,DISPOSAL PONDS ❑ Thereby 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 k 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." f jr The app lica all for all requir in pec" s. Complete draw' ' on reverse side. _ r Signed X Title: Date: ' FOR DEPARTMENT USE ONLY 5 -7 I ` Application Accepted by Date Jo Area 0 �` Pit or Grout Inspection by Date Final Inspection by ADate 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, g C K# 6 r RECEIVED BY DATE PERMIT�NO." + EH 13-24(REV.1/95) , - f+ C,O EH 1426