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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE ON AVE., STOCKTON, CA Telephone (209) 466-6781 > PERMIT EXPIRES 1 YEAR 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 weil/pump and the Rules and Regulations of the San Joaquin Local Health District. L >- r p 4:: f� C1PSI Job Address V#-" f � r � -k c-�� City � Lot S Owner's Name ... . ` r A R Address _ Phone �+ l II 3s�d ! d ' Contractor's _Name_ h _ . License No. Phone. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT D DESTRUCTION ❑ AMOUNT REMITTED CASH PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ PERMiT"NO. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS 1 INTENDED USE T TYPE OF WELL .. PROBLEM AREA CONSTR lON-SPECIFICATIO7:fS, ❑ Industrial ❑ Open Bottom t❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/ Private ❑ Gravel Pack Tracy Type of Casing Specifications ❑ Public _❑ ❑ Other f ❑ Deltas Depth of Grout Seal "° Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface,Seal In%alled by Repair Work Done ❑ ❑ Type of Pump H.P.'o - State Work Done w Diameter I Sealing Material (top 501 Well Destruction Well Depth E Filler Material {Below 56 1 S TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION LL-+WSTRUCTION ❑ (No septic system permitted if public sewer is i available within 200 feet.► Installation will serve: Residence Commercial Other Number of living units: _L_ Number of bedroom Character of soil to a depth of 3 feet- Water table depth SEPTIC TANK �fype/Mfg Ch ~ apacity No. Compartments PKG. TREATMENT PLT. D. Y 1 t �t Method of Disposal Distance to nearest: Well.. Foundation Property Line i LEACHING LINE M --Igo. & Length of lines "' ! _ ... Total length/size FILTER BED _ LJDistance to nearest: Well ;Foundation -Property Lirie` SEEPAGE PITS ❑ Depth rSize Number y SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ _f 1 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 pistrict. a Home owner or licensed agent's signature certifies the following: "I certify that ih 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 certifies the following: "I certify that in the performance of the work for which thii permit is issued, I shall employ persons subject to workman's compense- t' aws of California." #� The applic ust call fo al quit d ins #ions. C plate drawing on evere sl Title: Date: i �FORRTNIENT USi= ONLY Application Accepted by hate 2;2 Area IcyPR or Grout Inspection by f Date Final Inspection by Date i Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-71_04 0 Tracy 835-6385 Applicant - Return all copies toe Environmental Health Permit/Services 1601 E.�Hazelton Ave., P.O. Box 2009, Stk., CA 95201 sl•__•. - - - ... _. — .^.alts + EH 1324 (REV. 10183 EH 14-28 i FEEAMOUNT INFO DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMiT"NO.