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F APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT . 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1,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. I`. scl '' Job Address T J City Lot Size PM 1.� _ d Owner's Name I + � Address Phone '' .. Contractor ess License No.,/-/O/ hone �> TYPE OF WEL (PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ N SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE HYPE OF WELL PROBLEM 'AREA'CONSTRUCTIbN SPECIFICATIONS _ }' ❑ Industrial O Open Bottom C1 Manteca ,Dia. of Well Excavation Dia. of Well Casing 9 ` r 11 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications �r n Public _ ❑ Other Fl Delta. Depth of Grout Seal Type of Grout I I Irrigation ik-Approx. Depth I 1 Eastern iiSurface Seal Installed by - Repair Work Done ❑ . Type of Pump H.P. State Work Done ;p Well Destruction ❑ Well Diameter Sealing Material /top 501 - •-F - Depth" Filler Material (Below 501 1 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION [I OESTRUCTIO (No septic system permitted if public sewer is h. available within 200 feet.) V Installation will serve: Residence_ Commercial _ Other #` ° \ Number of living units: Number"of bedrooms dti Character of soil to a depth'�of 3 feet: Water table depth SEPTIC.TANK ❑ ype/Mfg Capacity No. ComI`Tpartments PKG. TREATMENT PLT. ❑ .E f - _ }. Method of Disposal Distance to nearest: ,Well Foundation `-' Property.Line LEACHING LINE ❑ No. & Length of lines -" Total length/size FILTER BEDS ❑ Distance to nearest: Well Foundation ` Property Line SEEPAGE PITS I 1 . Depth Size�_ Number SUMPS L] Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑E 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 District. i. I 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 applicant ust call for a1�r it ins tions. Complete drawing on reverse side. � r Signed f Title::' - Date: OR DEPARTMENT USE ONLY Application Accepted by tma A& Date Area i. Pit or Grout Inspection by , I� Date Final Inspection by Date U � ".. ,.. ..._.. ...;_ ,.:...:.,.-�...".,..-.5.x«.,4,,.. ..�-...�.•�.�...,.-.. .•�--.r.�.........,,,.,,..�... Additional Comments: I ❑ 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 FEE AMOUNT DUE AMOUNT REMITTED CIC INFO CASH RECEIVEDBY DATE PERMIT NO. a.EH 13-241REV.rrKsr � � EH 14"2B