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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 TYEAR-FROM DATE ISSUED (Complete in Triplicate) Application is helehy 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. t („� O S7 City Lot Size PM Job Address I Ito i Phone Owner's Name t S Address k lib cit Address ST License No.�V S Phone r Contractor TYPE OF WELL/PUMP: NEW WELL CI WELL REPLACEMENT ❑ DESTRUCTION 2%L 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 CONSTRUCTION SPECIFICATIONS r ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing V `� ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications [1 Public F1 Other ❑ Delta •r Depth of Grout Seal Type of Grout 'tel Irrigation �_Approx. Depth . I 1 Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done— Well ion ] Well Diameter IDyp Sealing Material flop 50') r" Depth ,.SD�� Nr Filler Material (Below 50'1*+ - TY E OF EPTIC WORK: NEW INSTALLATIOREi?AIR/ADDITION IOESTRUC ON l I [No septic system permitted if public sewer is • --available within 200#eet.l `' nstallation.will'serve:.�Residence GammArciaf_ Other iNumber of living units: Number of bedrooms ` Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments { PKG. TREATMENT PLT. ❑ Y Method of Disposal t Distance to nearest: Well Foundation Property Line k LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l 1 Depth Size _ Number P SUMPS D 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. k rtify that in the performance of the work for which this permifis issued,I shall.not Home owner or licensed agent's signature certifies the following: "I ce sO4' 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 must call for all required inspections. Complete drawing on reverse side. f Signed X 'Title: Date: FO E+PARTMENT USE ONLY Application Accepted by { Date Area Date Pit or Grout Inspection by Date Final Inspection by Additional Comments: 1 ❑ 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.Q. Box 2009, Stk., CA 95201 aIFEE NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT N0. + EH 13.24 tREV.1/K5) EH 14-28 v