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APPLICATION .FOR PERMIT . �-- SAN .10AQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL I ON 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. (�y� Job Address 2 �1 f Lot'Size PM - =Ci /9 - Owner's Name Address ,�/ 'Z ,_ Phone tea Contractor __Address License No. Phone 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 �FOUJNOATION AGRICULTURE WELL OTHER WELL- YPIT'S/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑Manteca Dia. of Well Excavation Dia. of Well Casing 11 Domestic/Private E3Gravel'Pack�O Tracy Type of C sirIg Specifications ❑ Public # ❑ Other ❑ Delta Depth of Grout Seal Type of Grout Irrigation 1 4 —_—Approx. Depth ❑ Eastern Surface Seal-installed-tiy r Repair Work Done ❑ Type of!Pump H.•P-:�"" � State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 ,J ,. Depth Filler Material {Below 501 f TYPE OF:SEPTIC WORK: NEW INSTALLATION 171REPAIR/ADDITION 1-1 DESTRUCTION Mo septic system permitted if public sewer is available within 200-feet.) i Installation--mijill'serve'` Residence Commercial— Other 1 t Number of living ng units. ' Number of bedrooms ..... L ` r I Character ofsoil to a depth of 3 feet -.� `" Water table depth SEPTIC TANK t ❑ Type/Mfg Capacity- Not Compartments PKGO TREATMENT PLT. 177V Method of Disposal 1 Distances efto nearest: Well Foundation Property Line • LEACHING LINE E3No.r& Length of fiTotal length/size nes 9 � FILTER BED ❑ Distance to nearest: Well Foundation PropertyLine ' 3 SEEPAG�PITS' ❑ Depth � � Size -=N�mber 4 I SUMPS ❑ Distance to negarest: Well Foundation Property Line s DISPOSAL PONDS ❑ I I I hereby�cartify that I have prepared As application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquih Local Health District. �^^ Home owner or licensed'�agent,s signature certifies the following: "I certify that in�the performance o theme wo' rk for which this permit is issued, I shall not employ any person in such mariner as to become subject to workman's,cvmpensatlon 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." i The appl�cA�mII f r II r ' ired inspections. Complete drawing on reverse side. Signed Title: Date: r FOR DEPARTMENT USE ONLY Application Acceptedby Date y}� Pit or Grout Inspectio k Date Final Inspection by Date 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 95261 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO CASH + EH 13-24 IR EV.iia 51 EH 14-26