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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ! 1601 E. HAZE T ON /`--VE ,�`STOCKTON, CA Telepho w,,Q^a} 4,=,5-6781 PERMIT EXPIRES 1'� E:aF3,s'# OM BATE ISSUED (Complete fi 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 E Local Health District. { Job Address City Lot Size .PM Owner's Namo ddress lie I Phone Contractor �Address '739 ja � License No. Phan ?".a�lC TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION _ PUMP INSTALLATION ❑ --- .� SYSTEM REPAIR,❑,, OTHER ❑ � DISTANCE TO NEAREST SEPTIC TANK�T-�'�"�f - -- SEWER LINES--•.�+•-�•-....,.,_.-.�-.�,.:.. _�__ ---Y-- DISPOSAL FLb.'" FOUNDATION — AGRICULTURE WELL OTHER WELL PITS/SUMPS a INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation �. ❑ Domestic/Private L ' Dia. of Wel! Casing ❑ Gravel Pack ❑ Tracy Type of Casing- n Public i ' ,f-1 Other Specifications ❑ Delta Depth of Grout Seal I I irrigation *' Approx. Depth I i Eastern Type of Grout _ Surface Sea! Installed by Repair Work Done ❑ ,Type of Pum p �r H.P. §tate Work Done Well Destruction ) Well Diameter ill _ Sealing Material (top 50') f L >k Depth Filler Material iBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION I 1 DESTRUCTION I ) 'No septic system permitted if public sewer is Installation will serve: Residence— Commercial ._ Other available within 200 feet.) Number of living units: —Number_of_bedrooms_.._. Character of soil to a depth of 3 feet: SEPTIC.TANK " Water table depth , ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINEl ; ' Cl No:•&-Length of lines Total length/size FILTER BED ❑ Distance to nearest: Welt- !! -'—` --IFoundatidh ' 1 Property Line y A SEEPAGE PITS i l� Depth " K f ` t Number SUMPS Ld Distance tolSize nearest: Well Foundation DISPOSAL PONDS Property Line a 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 I rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: _ employ an "I certify that in the performance of the work for which this permit is issued, I shall not em P y 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." The applicant mus; call for ail required inspections. Complete drawing on reverse side., ; 1 Signed F ..,�, Title: t Date: .a_ a A-5 FOR DEPARTMENT USE ONLY r Application Accepted by ` Date 1 — Area i Pit or Grout Inspection byi Final Inspection by Date 2/,,-.i Additional Comments: ❑ Stk 466-6781 ❑;Lodi 369-3621 El 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 FEE AMOUNT DUE AMOUNT REMITTED CK INFO CASH RECEIVED BY DATE PERMI7'NO. +.EH 14-24(REV.1 i H al