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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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." Job Address ✓ City Lot Size PM Owner's Name Address , Phone Sql Contractor,�l s © � x I Ulicense No. loone A� TYPE OF WELL/PUMP: NEW WE L ❑ WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION SYSTEM REPAI t ❑ OTHER,,O DISTANCE TO NEAREST: SEPTIC TANK .1.0-0-1-SEWER LINES 1 610 DISPOSAL FLD. 0 0 PROP. LINE M0 FOUNDATION AGRICULTURE WELL OTHER WELL Lam' PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation I j Dia. of Well Casing omestic/Private OrTravel Pack ❑ Tracy Type of Casing P Vc Specifications (I Public Ll Other ❑ Delta Depth of Grout Seal T no of Gut I I Irrigation _.Approx. Depth I I E tern Surface Seal Installed by r - Repair Work Done ❑ ype of Pump H.P. _,3 State Work Done Well Destruction [Well Diametter, � Sealing Material (top 501 �r Depth [7r6 Filler Material (Below,50') moire TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial Other .� 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 PKG. TREATMENT PLT. ❑ Method of Disposal 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 Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ hereby certify that I have prepared this application and that the work will be done,in accordance with San Joaquin county ordinances, state laws, ant�� rules and regulati f the San Joaquin Local Health District. Home owner icense gent's signature certifies th Ilowing: "I certify that in the performance of the work for which this permit is issued,1 shall not employ any arson in suc ma er as to b c me s I t to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies th followin :"I rti that' th r n ,of the rk for which this permi ' ssued,I hall employ persons subject to workman's compensa tion laws Califor 1a." The applic nt m II o All re it o . Com Ing on rev e side. Signed X Title: Date: _ FOR DEPARTMENT USE ONLY Application Accepted by Date -7 W Area J Pit or Grout Inspection by ��2�ADate 7- ZZ-Yy Final Inspection by ef Date.,' ` Additional Comments:- t1� _ ' �. >r ❑ Stk 466-6781 ❑ Lodi 369-3621 Manteca 823-7104 ❑ Tracy 835-63$5 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 ASH PECEIVED BY DATE PERMIT NO. INFO JC ♦.EH13-24(REV.1/85) �� EH 14-28 1110�� 1J if U 1