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APPLICATION FOR PERMIT • / SAN .lOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T 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. ++�� 2C 1.31 i C, Lot Sizet�L , P Job Address Owner's Name Address Phone Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL 71 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION O SYSTEM REPAIR LJ OTHER El DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE `} FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1`1 Public ❑ Other ,, ]- Delta Depth of Grout Seal Type of Grout --- I I Irrigation —.Approx. Depth I l Eastern Surface Seal Installed by - Repair Work Done L1Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION I I DESTRUCTION ilVo septic system permitted if public sewer is ailable within 200 feet.I Installation will serve: Residence X Commerciale Other Number of living units: Number of bedrooms 1 17 Character of soil to a depth of 3'feet:' Water table depth SEPTIC TANK � Type/MfgIMM Capacity. No. Compartments ✓� PKG. TREATMENT PLT. ❑ Method of Disposal t Distance to nearest: Well Foundation Property.Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED r ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l 1 Depth Size Number ; „SUMPS Ll Distance to nearest: Well Foundation Property Line j 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 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 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-"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." " The applicant st call for all required inspections. omplete drawing on reverse side. x Signed X e: Date: 1✓ FOR IDEPARTM T USE ONLY Application Accepted by _ _ Date Area kit-�- " t 4 oDate Pit-or-Grout-Inspection-by Dae Final.lns pactin by Additional Comments: �� - ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823- 104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMITNO. INFO +.ER 13-24(REV.t i n 5) 3S. EH 1428 t