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APPLICATION FOR PERMIT f SAN JOAQUIN LOCAL.HEALTH DISTRICT # 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application is he+eby 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 +i Local Health District, E 4*e Job Address �m City Lot Size PM f f//A�� y. ✓ Address �/ �� Phone Owner's Name l p f Contractor ' Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ry t PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ t I DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLO. - PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS [I Industrial ❑.Open Bottom. ❑ Manteca ,,, Dia. of'Well Excavation Dia. of Well Casing '� w � ON Domestic/Private 1:1Gravel Pack ❑ Tracy Type of Casing Specifications FI Public ❑ Other Fl Delta Depth of Grout Seal Type of Grout s I I Irrigation --Approx. Depth 1 I Eastern Surface Seal Installed by - ,y Repair:Work Done- ❑ Type of Pump H.P. State Work Done— Well n, L1Well Diameter Sealing Material Itop 501 4 +;_'`'Depth Filler Material.18elow_50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 RFPAIR/ADDITIO DESTRUCTION 'INo septic system permitted if public sewer is \ available within 200 feet.), Installation will serve: Residence Commercial Commercial Other i >- f Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg r Capacity No. Compartments PKG. TREATMENT PLT. ❑ _ 4 -1 Method of Disposal ' Distance to nearest: Well Foundation Property Line ' J . LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line r " SEEPAGE PITS L I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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. fHome 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 became 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 must call for all re ired spections. Complete drawing on reverse side. Signed X Title: Date:cx7 FOR DEPARTMENT USE ONLYi � Area Date ` � I Application Accepted by -7-` Pit or Grout Inspection by Date Final Inspection by a Date! / � Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 03-7,104 ❑ Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E.,Hazellon Ave., P.O. Bax 2009, Silk., CA 95201 �f 1 FEE 7AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY D TE PERMIT'NO. INFO _ EH 13-24iREV.i/H5Y - 3f�dt /��'� EH 14-26 i