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APPLICATION+FOR PERMIT , SAN JOAQUIN 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.hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is p 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 &as t Phone C Contracto Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE V+ r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF.,WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia- of Well Casing t ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy -Type of Casing Specifications r-1 Public F1 Other Cl pelta R --Depth of Grout Seal Type of Grout ` I Irrigation Approx. Depth l I Eastern Surface Saal installed by _ Repair Work Done ❑ Type of Pump H.P.- State Work Done Well Destruction ❑ Well Diameter Sealing Material (tap 501 Depth Filler Matefial (Below ) TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION DESTRUCTION INo septic system permitted if public sewer is " - available within 200 feet.) Installation will serve: ResidenceCommercial_ 'Other Number of living units: Number of be rooms j r _- Character of soil to a depth of 3 feet: f Water table depth s , t. SEPTIC TANK ❑ Type/Mfg p�� Capacity 1 No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation .- Property Line LEACHING LINE L1 No. & Length of lines 1 x 3 Total length/size 76tO F r (FILTER,BED ❑ Distance to nearest: Well Foundation la _ Property Line_b SEEPAGE PITS F, I:1 °bepth ' Size t _,•'t "Nur-bbr A- SUMPS L1 Distance to nearest: ., Well "" " ~'Foundation Property Line DISPOSAL PONDS ❑ ~t 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 District. " 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.-Cdntractorrs hiring or sub-contracting signature certifies the following: "I certify that i rformance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant ` olmek e ins ctions. Comp) . drawing o e arse side. Signed X Title: Date: FOR EPARTMENT USE ONLY Application Accepted by Data �� 7. Area Pit or Grout Inspection by Data Final Inspection by Date Additional Comments: n ❑ Stk 466-6781 ❑ Lodi .369421 ❑ 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 INFO MOUNT DUE AMOUNT REMITTED CK 4 CASH RECEIVED BY DATE PERMIT'NO. + EH1 -24 tpEV. '' J� EH 14-2ti