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r APPLICATION FOR PERMIT I :... SAN JOAQUIN LOCAL HEALTH DISTRICT J 1601 E. HAZEL i 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..186.2_for welltpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address `' r"' � City Lot Size PM i Owner's Name Address Phone Contractor -G r r Address License No. 7 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION O � { i -PUMP INSTALLATION. ❑ SYSTEM REPAIR ❑ OTHER ❑ r DISTANCE TO 0 NEAREST: SEPTIC TANK_ _ SEWER.LINES ..DISPOSAL FLD:----— PROP.-LINE- FOUNDATION ROP.-LINE-FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public , ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ 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 TYPE OF SEPTIC WORK: NEW INSTALLATION: REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.i Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms P Character of soil to a depth of 3 feet:4 - Water table depth SEPTIC TANK 0( Type/Mfg , Capacity No. Compartments PKG. TREATMENT PLT. ❑ `` / / Method of Disposal 1' �Distance,to nearest: Well �b Foundation�Ci Property Line 70 LEACHING LINE "No. & Length of linen a Total length/size FILTER BED 71 Distance to nearest: Well Foundation Property Line s SEEPAGE PITS 0 DepthSize Nrmber SUMPS A X Distance to nearest: Well Foundation Property Line �a DISPOSAL-PONDS ❑ ' l 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 1 11�rules and regulations of the San Joaquin Local HealthDistrict. 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." Contractors 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 must call for all required ihspections.:Complete drawing on reverse sider4 Signed X1w+1��:��lir, I `' _ =•_ -Title: '` Date• 13 a FOR DEPARTMENT USE ONLY, Application Accepted by x Date Area i Pit or Grout I-nspection by `"i '� Date" " -- "Final 16ijP6 tion by Date �� ? Additional Conimerits: ❑ Stk 466-6781,` b Lodi;/369-3621 ;, El Manteca 823-7104 _CJ Tracy 835-6385 �I Applicant,- Return all copies to: Environmental.Healfh"Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 41, FEE AMOUNT DUE AMOUNT REMITTED CK R 'i RECEIVED BY DATE PERMIT`Nd.. 1NfO CASH + EH1324(REV.t/851 EH 14-26