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G APPLICATI_?N,F ''R PERMIT -� mom. ,� t SAN JOAQUIN LOCAL HEALTH DISTRICT i 1601 E. HAZELTON AVE.,.,STOCKTON, CA Telephone (209) 66- 6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) F 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 i 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. Lo"'Size PM. 9 1 O tom.. t . ' Job Address � I�Q t,� ••� � I 6.1 city G k Address ' ti +^^� Phone Owner's Name Contractor Address `av) License No. Phone�eS 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 .I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ll Industrial L3Open Bottom C1Manteca Dia. of Well Excavation Dia. of Well Casing ' Y'Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other` ❑•Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal installed by Repair Work Done 54: Type of Pump Sr�r� H.P. State Work Done r� Well Destruction ❑ Well Diameter Sealing Material (top 50')= r Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is i - available within 200 feet.) Installation will serve: Residence— Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: F Water table depth 1 SEPTIC TANK ❑ Type/Mfg _ /Capacity No. Compartments " C Method of Disposal PKG. TREATMENT PLT. 0� Distance to nearest: Well Foundation Property Line r LEACHING LINE.. ❑ No. & Length of lines Total length/size FILTER BED, w— El, Distance to nearest: Well -Foundation Property Line SEEPAGE PITS ❑ Depth Size _ Number i SUMPS, "" "`- D. Distance to nearest: Well +'Foundation Property Line DISPOSAL PONDS ❑ f 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. a 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."Contractors hiring or sub-contracting signature F 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." ,+•- - . i The a ant uac st call for all r ired ins tions. mplete drawing on reverse side. ,- Title:1. Q - Date: d Signed X ` — —z R ` ` FOR DEPARTMENT USE ONLY �Applicatiori Accepted by DatteArea Pit or Grout Inspectio ' Date Final Inspection Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 + Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 FEE AMOUNT DUE AMOU T REMITTED CASH RECEIVED BY DATE PERMIT-NO. INFO f g + EH 13-241REV. EH 1426