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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA E!Vi�`t 4 ' r�� Telephone (209) 466-6781 SEP 13 � PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) E«V1RONMEi €RL IH Al T H Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the worleff,9A es rig .,f4i" p icwion 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. n t City Lot Size PM Job Address �( (� Address v/ e Phone Owner's Nam nse Nof Phone�� Contrac r TYPE OF WELL/PUMP: I NEW WELL ❑ WELL REPLACEME ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS .. _ .� -... .._... _ .__ INTENDED USE TYPE OF WELL PROBLEM'AREA SPECIFICATIONS ❑ industrial L1 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing �.-a- stic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications - 4J {-1 Public ❑ Other ll Delta Depth of Grout Seal Type of Grout y r ` I I Irrigation \_ � _ II'..Approx. Depth/ { 1 Eastern S rface Seal Installed by Repair Work Done Iy i �r 16 of Pump H.P. I!�� - State Work Done (Q') Well Destruction / ❑ Well Diameter Sealing Material (tap 501 I Depth L ��-- Filler Material (Below 501 -- i I DESTRUCTION l 1 INo septic system permitted if public sewer is TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION „�� a available within 200 feet.) Installation will serve: Residence /Commercial— Other Number of living units: t _Number of bedrooms r Character of soil to a depth)of 3 feet: ' Water table deplfi ` SEPTIC TANK 1-1I1Type/Mig Capacity No. Compartments � PKG. TREATMENT PLT. ❑ Method of Disposal Y Distance to nearest: Well Foundation Property Line I - of Total length/size LEACHING LINE Ll No. &,Length of lines '� � � FILTER BED L] ! Distance to nearest: Well Foundafio� Property Line y SEEPAGE PITS I I Depth t Size 'Number 4 ` SUMPS 0 Distance to nearest: Well_`'Foundation=- Property Line DISPOSAL PONDS ❑ - � ~ ` --- .r ._ I hereby certify that I have prepared this application and that the work will be on yin c�idance with San Joaquin cbunty cl d antes, state laws;and rules-and-regulations of-the gan-Joaquin-Local Health-DFstrict- Home owner or licensed agertit's signature certifies the following: ,d 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 subje'c`t to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certilfy that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- i tion laws of California." : i The applicant must all or all required inspections. Complete drawing on t se side Sig a Titl Date: 1 i FOR DEPARTMENT USE Application Accepted by Date / � Area Pit or Grout Inspection by Date Final inspection by -Z> DateL r I� ' Additional Comments: - ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copieslto: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMDUNT DUE AMOUNT REMITTED CASH RECEIVED 6Y DATE PERMIT'NO. INFOLi /I� q EH 13-24(REV.iinsl / '77I O f2-1 EH 1l-2a