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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601- E. HAZEL—i ON AVE., STOCKTON, CA Telephone-12091 466-6781 PERMIT EXPIRES1 YEAR`FROM DATE`ISSUED {C&nplete 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 Son Joaquin County.Ordinance No.549 forsewageor No. 1862 for ell/pump and the Ryles and Regulations of the San Joaquin Local Health District. 7� �r3LZ, Job Address E !` / /Kms/ { City` ,Lot Size 'PM Owner's Name - Address=- - Phone Contractor Address License V Phone TYPE OF WELL/PUMP:' NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 1; FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack} ❑ Tracy Type of Casing Specifications ❑ PublicY❑ Other ❑ Delta `s Depth of Grout Seal +' Type of Grout ❑ irrigation �4pprox Depth ❑ Eastern Surface Seal Installed by Repair Work Done. ❑ -" Type of Pump H.P. State Work Done Well Destruction y❑ `-Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 f' I a TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ No septic system permitted if public sewer is t t available within 200 feet.) Installation will serve: Residence Commercial_ Other iR 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 PKG. TREATMENT PLT. ❑ Method of Disposal Y n Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines t'_ Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size - Number- SUMPS ❑ Distance to nearest: Well Foundation Property.Line l DISPOSAL PONDS ❑ r 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. 41 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." Contractors hiring or sub-contracting signature 1 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 i spections. Complete drawing on reverse side. Signed Title Date: FOR DEPARTMENT USE ONLY Application Accepted by Date -�Ck S Area Pit or Grout Inspection by Date final Inspection by DateLd s� d Additional Comments: ❑ Stir 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 95201FEE #� r INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO.' - +EH 4(REV.S/85) EH 14-2jV w O-� i - �yc:1 8S-1o�Ff .