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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i ON AVE., STOCKTON, CA s 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 welllpump and the Rules and Regulations of the San Joaquin Local Health District. i Job Address City Lot Size PM Owner's Name (, Address Phone Contractor Address '� License No. ` ` Phonm�eT TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO, FOUNDATION AGRICULTURE WELL OT L PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRU SPECIFICATIONS ❑ Industrial El Open-Bottom ❑ Manteca o Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack"'"" ❑ Trac' "' _Type of Casing ` Specifications FI l Public ❑ Other 6 elta Depth of Grout Seat ? Type of Grout I I Irrigation _.Approx. Depth i I Eastern Surface Seal Installed by - G Repair Work Done ❑ Type of Pum H.P. S Pump'p tate Work Done Well Destruction ❑ Well Diameter . Sealing Material (top Sa'i r Depth tom. Filler Material iBeIOW 60'1 ' 111 TYPE OF SEPTIC WORK: NEW INSTAL'L'ATION Ia REPAIR/ADDITION I I DESTRUCTION iNo septic system permitted if public sewer is \ available within 200 feet./ Installation will serve: Residence? Commercial_ Other 1 w n� Number of living units: Number of bedrooms. Character of soil to a depth of 3 feet:e Water table depth ° +-s Ca achy-_ No. Compartments SEPTIC TANK 0 Type/Mfd _4 p PKG. TREATMENT PLT. El —Y- �— W----��-- . Method of Disposal Distance to nearest:-' Well Foundation Property.Line I r LEACHING LINE r ❑ No. & Length of lines Total length/size FILTERBED f F1Distance}o nearest: (Nell ' .t Foundation Property Line SEEPAGE PITS ' I'I••Depth " Siie"� ° .Number` SUMPS `-:Ll Distance to nearest: Well Foundation Property Line i DISPOSAL PONDS i}} ❑ 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 r rules and regulations of the San Joaquin Local Health Di1trict. i i Home owner or licensed agent's signature certifies the following: "1 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 tbbjett 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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant m call for all required spe 'ons._Complete�'drawing on reverse side, I Signed X Title: _ _ Date: 7 ` FOR DEPARTMENT USE ONLY Area Application Accepted by Date Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ 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 INFO AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT NO. +.EH13-24iREV.�iw51 S r/�/ rl• EH 14-29