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I i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ti 1601 E. HAZELTON AVE., STOCKTON, CA Telephone {209) 466-6781 l PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 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 Application 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. Y Job Address City Lot Size PM ' 3 r OLS Owner's Name Address Phone Phoneg r� 3 Contractor's Name cense No. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR 11OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i FOUNDATION AGRICU UTU REL WELL. OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Excavation Dia. of Well Casing ❑ Industrial LJ Open Bottom El Manteca "Domestic/Private ❑ Gravel Pack O Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I r ❑ Irrigation �4pprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State rk Done Well Destruction Well Diameter Sealing Material Itop 50') Depth Filler Material (Below 50'1 414 ssrniOp TYPE OF SEPTIC WORK: NEW INSTALLATION LJREPAIR/ADDITION 13 DESTRUCTION ❑ available(Nolwithin 200 feettted if public sewer is ry Installation will serve: Residence— Commercial— Other S Number of living units: Number of bedrooms — Character of soil to a depth of 3 feet: 114, Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line I SEEPAGE PITS ❑ Depth Size Number t SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ hat the work will be done in accordance with San Joaquin county ordinances, state laws, and I hereby certify that I have prepared this application and t k 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 i employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature i 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." Theapplicant must call r all required inspecti s. Complete drawing on re�erse side. Signed Title: Date: FO DE ARr T USE ONLY f Application Accepted by Date Area k Pit or Grout Inspection by Date =Inspection Date L Additional Comments: 1 ❑ Stk 466-6781 ❑ Lodi 369-3621 C3 Manteca 823-7104 ❑ Tracy 835 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, StII CA 95201 FEE AMOUNT DUE AMOEREMITrED RECEIVED BY DATE PERMIT NO. INFO t +EH 13-24 IREv.101831 �( X73 C EH 1426 .. ._...