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y - y APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �S �� 1601 E. HAZELTON AVE., STOCKTON, Cc hlA aSJ li Telephone 12091 466-67$1 f G �h d -�&h PERMIT EXPIRES 1'YEAR FROM DATE ISSUE (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wor is 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 i Local Health District, JD U - City 512PC Lot Size PM Job Address2al i i 's Name Address Y Phone ;;2_��2 Owner Contractor _ Address License Na. - Phone TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ tPUMP INSTALLATION El SYSTEM REPAIR 11 OTHER ❑ '�_- . DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 1 FOUNDATION AGRICULTURE WELL OTHER WELL- INTENDED INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing ❑ industrial ❑ Open Bottom FlManteca Dia. of Well Excavation Type of CasingSpecifications ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy _ x r Cl Other F1 Delta F Depth of Grout Seal Type of Grout M Public r I I Irrigation Y x —.Approx. Depth I 1 Eastern Surface Seal Installed by X - Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction 0 Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 50'I TYPE Of SEPTIC WORK: .NEW INSTALLATION 1.1 REPAIR/ADDITION l 1 DESTRUCTION (No septic system permitted if public sewer is available within 200 feet./ i. Installation will serve: Residence— Commercial'— Other Number of living units: f Number of bedrooms Character of soil to a depth of 3 feet: Water table depth 1 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments i PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ No. & Length of lines Total length/size I FILTER BED LJDistance to nearest: ' Well Foundation Property Line ' Size Number SEEPAGE PITS 1.1 Depth SUMPS ❑µ Distance to nearest: Well 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 District. r allowing: "I certify that in the performance of the work for which this permit is issued, I shall not Home owner.or licensed agent's signature certifies the f employ any person.�n such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature f certifies the following: "I certify that in the performance of the work for which this permit.is issued,t shall employ persons subject to workman's compensa- tion laws of California." y The applicant ust for all require inspections. Complete drawing on reverse side. r Title: Date: G Signed X "- FOR DEPARTMENT USE ONLY Application Accepted by Date� 6 � Area Pit or Grout Inspection y Date Final Inspection by Date Additional Comments: 3® 1 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 ❑ Tracy 635-6385 Applicant - Return all copies to:'Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE K RECEIVED BY DATE PERMIT'NO. ` 4 INFO FEE AMOUNT DUE AMOUNT REMITTED TER EH 13-24 1F1EV.1/A 57 EH 14-26