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APPLICATION .FOR PERMIT l SAN JOAQUIN LOCAL HEALTH DISTRICT . 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES i'YEAR FROM DATE ISSUED (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 Rules and Regulations of the San Joaquin Local Health District.. �. 4psJob Address City Lot Size PM -� { Owner's Name Address � l- 4_ Phone�� / Contractor Address l %��/I / � ` License No T Phonq4&76 e A ti 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 ❑ Manteca Dia. of Well Excavation Dia. of Well Casing =� ❑ Domestic/Private ❑ Gravel Pack 0-Tracy Type of Casing Specifications `tl F] Public ❑ Other' . .11 Delta Depth of Grout Seal Type of Grout _ I I Irrigation __"Approx. Depth I;I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P.' State Work Done_ Well Destruction ❑ Well Diameter "" ,.,Sealing Material (top 50'1 Depth ` Filler Material IBelow 50'1 r S TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION A DESTRUCTION i I (No septic system permitted it public sewer is t available within 200 feet.) Installation will serve: Residence Y Commercial Other 4� Number of living units: _L_ Number of bedroo Q'� r Character of soil to a depth of 3 feet: ^ Water table depth SEPTIC TANK ❑ Type/Mfg CT Capacity No. Compartments �• a PKG. TREATMENT PLT. ❑ '" """" '"° Method of Disposal Distance to nearest: Well 'Foundation Property Line `= J Jr LEACHING LINENo. & Length of lines ! d Total length/size , FILTER-BED 11Distance to nearest: Well -Foundation 1p rf Property Line i SEEPAGE PITS V� Depth Size_ _ Number SUMPS ❑- Distance to nearest: Well _ Foundation Property ` Line DISPOSAL PONDS ❑ 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 Di1trict. 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." t,r The applicant must call for all required ins ctigns. Complete drawing on reverse side -! _ �-' Signed X Title: Date: FOR DEPARTMENT USE ONLY Ap lication Accepted by Date Araa ' it Grout Inspection by Date 1 rFinal inspection by to Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 D'Manteca 823-7104. racy 835-6385 + A.P10 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE INFO AMOUNT DUE AMOUNT REMITTED CK 4 CASH RECEIVED BY DATE PERMIT'NO. +.EH 13-24(11 EV.tin 5l /}!� EH 14-2e �� r4J V G �r^:-�{r