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APPLICATION FOR PERMIT (1 l,Q SAN JOAQUIN LOCAL HEALTH DISTRICT /� 1601 E. HAZELTON 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. �-3 -2 2—S 57 V City L1ot Size t''/I PM Job Address � Phone Owner's Name '!,7/��'�f Address Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 11 y PUMP INSTALLATION ElSYSTEM REPAIR ❑ OTHER ❑ n DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ,- DISPOSAL FLD. PROP. LINE `"pU FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 7 Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 1] Domestic/Private O Gravel Pack Type of Casing 0 Tracy 9 Specifications ('I Public n Other Cl DeltaDepth of Grout Seal Type of Grout --- I I Irrigation T_Approx. Depth I I Eastern Surface Seal Installed by i Repair Work Done ❑ Type of,Pump H.P: State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Dlepth Filler Material (Below 501 TYPE OF SEPTIC WORK: IEW INSTALLATION t I REPAIR/ DITION I I DESTRUCTION I 1 (No septic system permitted if public sewernis a v ila gleewithin 200 feet.) Installation will serve: Number of 9iwnReident units: umber of bums. Other !� g Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ �A / Method o'f Disposal Distance to nearest: Well �c.G'Q �Foundatior Property Line LEACHING LINE No. & Length of lines Tot�l length/size FILTER BED ❑ Distance to clearest: Well oundation Property Line SEEPAGE PITS I I Depth Size Number ❑ Distance to nearest: Weil Foundation Property Line DI ❑ li 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 r:Ples and regulations of`the San Joaquin Local Health 011trict. Home owner or licensed agent's signature certifies the following: "I certify that in ithie pei*rmance 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 lawl of California,"-Contractor's Prising or sub-contracting signature certifies the following:"I certify thOt in the performance of the work for Which this Kermit is;issued,1 shall employ persons subject to workman's compensa tion laws of Caiifornia. _ r 6 The app�c�ucall all r quired in trio . Complete drawing on revefse side. w �� t Signed / Title: _. FCI MENT'USE®NLY Application Accepted by fY Date 1 Area Pit 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 FEET AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO +.EH 13-24(REV,I EH 14-26 �_,.. ......_. _.