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APPLICATION FOR PERMIT t >� SAN JOAQUIN LOCAL HEALTH DISTRICT `1 A 1601 E. HAZELTON AVE., STOCKTON, CA �( ��y "` Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application i e11 de to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in co an Joaquin County Ordi ance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Healt t c . ` Job Address City L t Size P #jqoo Owner's Name �/`_ir ��_ -�"� Address Phone l r o Contractor dressLicense No. 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 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �4 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS El Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public ❑ Other F1 Delta Depth of Grout Seal Type of Grout I I Irrigation __.Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 , Depth Filler Material (Below 501 -- C TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is (� Coavailable within 200 feet.) �+ Installation will serve: Residence_ mmercial_ Other ' Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: A Water table depth SEPTIC TANK ElType/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Found 'on_ Property Line sw LEACHING LINE ❑ No. & Length of lines Total length/size Is U FILTER BED ❑ Distance to nearest: Well Fo ndation Property Line o SEEPAGE PITS I I Depth Size Number O 1i n SUMPS Ll Distance to nearest: Well/� Foundation�— Property Line A 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, and rules and regulations of the San Joaquin Local Health Di§trict. 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." Contractor's 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 st call for required i spections. Complete drawing on reverse side. Signed X , Title: jJr'F Date: FOR DEPARTMENT USE ONLY Application Accepted by 1 Date Area Pi or Grout Inspection by Date Final Inspection by Date 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 " FEE AMOUNT DUE AMOUNT REMITTED CK INFO C SH RECEIVED BY DATE LJ PERMIIT'NNO. EH 13-24(REV.i i N 5)26 EH 14- 172 t,