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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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. r Job Address eJ City*m d Lot Size PM Of Owner's Name 9.. .- AddressPhon Contract F Address /~ License No; Phone TYPE OF WELL/PUMP: NEW WELL( WELL REPLACEMENT El DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ II cc 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 CONSTRUCTION SPECIFICATIONS ❑ Industrial XOpen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Kkir -u2ezL . Specifications ��/ F] Public f� O r. 1-1 Delta Depth of Grout Seal Type f Grout qC I I Irrigation 6_i 7,q-eAApprox. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Des action Well Diameter Sealing Material {top 50'1 ��5 Filler Material {Below 50') -- TYPE OF SEPTIC WOFW; NEW INSTALLATION l 1 REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is 'available1lihin 200 feet.) Installation will serve: Residence____ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth r, SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments \ PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size r FILTER BED ❑ Distance to nearest: Well Fo nd�tj�p1 Property Line "a SEEPAGE PITS i I Depth Size Number SUMPS LI ` DiaMn'c'e'to riea�esv —Well -' '— Foundation - Property tine'-- DISPOSAL PONDS n 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, f shall employ persons subject to workman's compensa- tion laws of California." The applica t �,usT�cca''l`'l C�i+for all required inspections. Complete drawing on reverse side. q Signed X �u�s/' W Z)� Title: Date: FOR DEPARTMENT USE ONLY 67 Application Accepted by Date 7, Area ( - Pit or G ou Inspection by Date a/ay Final Inspection by Date Additional Comments: Cl 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 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE EF/ NO. INFO /� jCASH ,jj + EH 13.241REV.ti N5) f .(/� /� S,/ /��3 f/ '✓ !' r"fEH t4-28 !!