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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 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. / q ! t� City r Lot Size M Job Address Owners Name' In Address —� Phoria Contractor �8 Qh Address- 5 � I't License No.SN 3-Phone � e� TYPE OF WELL/PUMP: NEW WELL-&'/ WELL REPLACEMENT LJ DESTRUCTION ❑ PUMP`INSTALLATION f� -j SYSTEM REPAIR ❑ OTHER EI DISTANCE TO NEAREST:'SEPTIC TANK . SEWER LINES° DISPOSAL FLD` PROP. LINE .� If;._ .r "FOUNDATION AGRICULTURE WELL OTHER WELL_IDL1F- PITS/SUMPS _ INTENDED USE T>Y'E OF WELL L-- PROBLEM AREA CONSTRUCTION SPECIFICATIONS 14 ❑ Industrial Open Bottom E] Manteca Dia. of Well Excavation Dia. of Well Casing [( Domestic/Private ❑ Gr°ave) Pack ❑ Tracy Type of Casing Specifications } 17 Public ❑ Other 171 Delta Depth of Grout Seal 4ype a( Grout — '� .Approx. Depth l 1 Eastern Surface Seal Installed by I I Irrigation State Work Dane _ Repair Work Done 11Type'of Pump H.P. Well Destruction ❑ Weil-Diameter {. ...-- Sealing Material (top 501 r ` Depth , Filler Material (Below 501 r TYPE OF SEPTIC WORK: NEW INSTALLATION [1 REPAIR/ADDITION l I DESTRUCTION l 1 INo septic system permitted if public sewer is available within 200 feet.) t Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms i Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments Q PKG. TREATMENT PLT. ❑ Method of Disposal J� Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number "-------- SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 Di§trict. ertify that in the performance of the work for which this permit is issued, I shall not Home owner or licensed agent's signature certifies the following: "I c employ any person in such manner as to become subject to workman's compensation laws of California." Contractors 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 f r all require specti s. Complete drawing on reverse std 9 Signed X Title: Date: r r 12 _�� FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date . , h Additional Comments: n LL tic ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Man eca 104 ❑ 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 CASH RECEIVED BY DATE PERMI7'NO. INFO r.EH 1324(REV.t/H 51 1j'1 S P EH 14-26