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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 4 �5 1601 E. HAZEL TON AVE:, STOCKTON, CA •TeIephone�f @)!,466=6781 PERMIT EXPIRES 1 YEAR FROM DATE `ISSUED ' (Complete in Triplicate)- +' a r .. yy�� , ., •1,:,: s '3.:.,'',_ '., ..a r.. J., F'_ 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. 1852 for well/pump and the Ryles and Regulations.of the San Joaquin Local Health District: u;' ::, i.. , r .t a`,y ''� Ci of Slze PM. Job Address T " Q, - Address" j n Phone A ' Owne�r's�Name�. -- v, ` !I , y ContractoF=�� !•► ddress gQ �J� L License NJZL� Phone TYPE OF WELL/PUMP: NEW WELL ❑ � -. WELL REPLACEMENT ❑ DESTRUCTION ❑ q PUMP INSTALLATION SYSTEM REPAIR D OTHER.D DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE �. TM FOUNDATION'' '"'" AGRICULTURE WELL y —OTHER WELL-== S PITS/SUMPS' INTENDED USE TYPE OF WELL -- PROBLEM AREA CONSTRUCTION SPECIFICATIONS y ❑ Ind ial ❑ Open Bottom EI-Manteca Dia. of Well Excavation Dia. of Well Casing { 5 ecifici tions rn omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing P � " f ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type•of Grout r 1 Elri irgation pprox. Depth��0_Eastern Surface eal I st led by Repair Work.Done Type of Pump r1 M I rC� �t l State Work Done I L,n' V y Well Destruction ❑ Well Diameter Sealing Material atop 1 Depth Filler Material Melow 50'1 .� t TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is available within 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 ' SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments 'I PKG. TREATMENT PLT. 71Method of Disposal ,.. Distance to nearest: Well Foundation Property Line LEACHING LINE C1 +No. & Lengthiof lines - 1' Tdtal length/size } { 4 FILTER BED El Distance to nearest: Well `" Eound6ti n _ ^`.Ergpprty,Line-_ - -•- - SEEPAGE PITS ❑ Depth Size Number '+t SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ �i '- }x-� —I-hereby certify that 1 have prepared this application and that the work will be done in accordaince with San Joaquin county""oidinances, state laws, ands rules and pe ions o Ian Joaquin Local Health District. Home ner or licensad age signature certifies the following: "I certify that in the performance of the work for which this permit is issued, ! shall not emplof any person in such man eras to become subject to workma compensation laws of California."Contractor's hiring or sub-contracting signature certifi s the following:"I certify hat i the performan of the o for ich this permit i ed, i shall employ persons subject to workman's compensa tion I ws of California." # The ap icant must c r II re ired ins on r arse side. Signed Title: Date: FOR DEPART ENT USE ONLY z r " Date Area 1 Application Accepted by t- Pit or Grout Inspection by Date Final Inspection by Date J Additional Comments: ❑ 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 FEEP AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO r + EH 13-21(REV.i/e 5) EH 1428