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t - J APPLICATION FOR PERMIT _ Y SAN JOAQU1N LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is heieby made to the San Joaquin Local Health District for a permit to construct and/of install the work herein described. This applicationis made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welllpump and the Rules and Regulations of the San Joaquin Local Health District. y j� % ,zea PM ' Job Address 0 City5/ U�r Lot Size Owner's Name Address r Phone Contractor Address License No, Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ ' " " SYSTEM REPAIR ❑ OTHER ❑ DISTANCE.TO NEAREST: SEPTIC TANK, SEWER LINES DISPOSAL FL-D. POOP. LINE I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ir t '❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Wel! Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I 1 Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout . 1;1 Irrigation _Approx. Depth l I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 Depth Filler Material l$elow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ( 1 R::'AIR/ADDITION I I DESTRUCTION INo septic system permitted if public sewer is try available within 200 feet.) Installation will serve: Residence__ Commercial_ Other 'jam.-jam 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 d I PKG. TREATMENT PLT. ❑ Method of Disposal F z Distance to nearest: Well Foundation Property.Line' 4 LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number S SUMPS ❑ 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, an 1 ;n rules and regulations of the San Joaquin Local Health District. I 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, ! shall not employ any person in such manner as to become subject to workman's compensation taws of California." Contractor's hiring of sub-contracting signature certifies the fallowing: "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." Y )If The applicant must c !I required ins ctions. Complete drawing on reverse side. Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by �.�� _— Date Area Pit or Grout Inspection by Oai Final Inspection by Date Additional Comments: JC"7 "Z Eris ''' ❑ 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 CHECfIVER 8Y RATE PERMiT'NO. FEE AMOUNT RUE AMOUNT REMITTER A r INFO t.EH 1 3-24 4REV.i/H 5) lag EH 14-2a `