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e a " APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) a 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. Job Address Com- City Lot Size PM Owner's Name r! ddress fPhone �1Contractor '� Address License No. Phone TYPE OF WELL/PUMP: 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 ❑ Open Bottom CI Manteca Dia. of Well Excavation, Dia. of Well Casing ❑ Domestic/Private 17-1GravelPack ❑ Tracy Type of Casing_ Specifications f 1'Public 171 Other n Delta Depth of Grout Seal Type of Grout _ I hrigation —Approx. Depth l I Eastern Surface Seal Installed byAP Repair Work Done ❑ Type of Pump �- H.P. I State Work Done Well Destruction A Well Diameter _ 'Sealing Material (top __' -7 — 11' Depth sFiller Material (Below 501 i T ;.TYPE OF SEPTIC WORK: NEW INSTALLATION 1 ) REPAIR/ADDITION I DESTRUCTION I I (No septic system permitted if public sewer is t available within 200 feet.i E Installation will serve: Residence s>Commercial Other i !Number of living units: Number of bedrooms, �f Character of soil to a depth of 3 feet: Water table depth 1 SEPTIC ❑ Type/Mfg - Capacity E No. Compartments. PKG. TREATMENT PLT. ❑ ! �t �' Method of Disposal `F Distance to nearest: Well Foundation Property Line r � } n LEACHING LINE ❑ No. & Length of li es1r r " Total length/size { FILTER BED ❑ Distance to nearest: Welly `� Foundation Property Line SEEPAGE PITS I 1Depth S ie fi Number t SUMPS L� Distance to nearest: Well, 7 Foundation Property Line DISPOSAL PONDS ❑ } 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 Di§trict. 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."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 applicari , require tions. Complete drawing on reva rte side. igned X Title: Date: .FOR,.DEPARTMENT,6SE ONLY Application Accepted by - :- Date Area Pit or Grout Inspection bey - _ Date Final Inspection by Date 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, Sik., CA 95201FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. +.EH 1J-241REV.IiM5) EH 11-28 S