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APPLICATION FOR PERMIT l SAN JOAaU1N LOCAL HEALTH DISTRICT f. 1601 E. HAZELTON AVE., STOCKTON, CA i Telephone (209) 466-6781 � PERMIT EXPIRES 1 YEAR FROM DATE ISSUED li (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 j 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 3 Local Health District. Job Address ` '�`-- 1� City Lot Size { f� Owner's Name Addressr Phone 41 Address l ense No yy hone s Contract ' TYPE OF WELL/PUMP: NEW WELL Lam^^ WELL REPLACEMENT ❑ DESTRUCTION ❑ j PUMP INSTALLATION ❑ SYSTEM REPAIR ED OTHER 1-1 DISTANCE TO NEAREST: SEPTIC TANK / c+�Y rSEWER LINES_ DISPOSAL FLQ.� PROP. LINE FOUNDATION f AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 01 / Dia- of Well Casin ❑ Industrial �'f1'Battom 171 Manteca Dia. of Wel[ Excavation �� ' � Type of Casing Specifications ❑ Domestic/Private ❑Gravel Pack ❑ Tracy YP g � � 1 [`I Public f] Other H Delta Depth of Grout Seal d r of ro t I I Irrigation Approx. Depth I I astern Surface Seal Installed b__y - - Repair Work Done L] Type of Pump � M.P. State Work Done Wel[ Destruction ❑ Well Diameter Sealing Material Itop 50') Depth Filler Material (Below 501 — TYPE OF SEPTIC WORK: NEW INSTALLATION 1:1 REPAIR/ADDITION I I DESTRUCTION i I (No septic system permitted if public sewer is available within 200 feet.i .F` Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg _Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED LJDistance to nearest: Well Foundation Property line SEEPAGE PITS l I Depth Size Number SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ T -' 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. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work foi 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 certifies the following: "I certify that in the performance of the wdrk for which this permit-is issu edj,i shall employ persons subje to workman's compensa- lion laws of California." s -- r The applicant must call for ail required inspections'C plate drawing on reverse side. SignedX_ � '"L Title: Date: 6,014-t- /7 FOR DEPARTMENT USE ONLY Application Accepted by a Date_ �`r Area t Pit or Grout Inspection by Data r��—� //Final Inspection byti Additional Comments: �-✓ t d ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 ❑ Tracy 835.6385 ". Applicant- Return all copies to: Env onment I Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT NO. INFO a.EH13-24 tREV.I/A 51 { EH 14-26 I