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APPLk'CATION FOR PERMIT SAN JOAQUIN'LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA ?C.— �e4Puk c o 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 SIOC --.tet Size PM Owner's Name Address Phone Contr.actar Address r License 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 T FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PR06LEM AREA CONSTRUCTION SPECIFICATIONS R"❑ Industrial 11 ❑ Open Bottom ❑ Manteca Ria- of Well Excavation Dia. of Well Casing X.Domestic/Priv ate ❑ Gravel Pack ❑ Tracy Type of Casing - Specifications 1-1 Public t 11 Other Cl Delta Depth of Grout Seal # •'+ Type of Grout — I I Irrigation .-Approx. Depth I I Eastern SZrfe Seal Installed by. _ Repair Work Done Ip Type of Pump H,P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 R Depth Filler"Material IBelow 50') 6 TYPE OF SEPTIC WORK: NEW INSTALLATION Cl RE=PAIR/ADDITION I I DESTRUCTION 1.1 Mo 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 Y PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property.Line LEACHING LINE r❑"'N5—&-length of lines Total length/size FILTEWBED. ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS, 11 Depth r Size Number SUMPS ° ❑ Distance to nearest: Well Foundation, Property Line tee,' Ott DISPOSAL PONDS i ❑ I hereby"certify that I Have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state la s, an 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." 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 applica t call for all required in ction ompl drawing on averse.side. ,1 k'•R i r Signed X' Title: �� Date: E `FOR'DEPARTNIENT USE ONLY C Application Accepted by -' " Date Area Pit or Grout Inspection by Date Final Inspection by 7?1 Date �. 1 Additional Comments: - ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 _❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601,E:Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT RE ITTED CK CASH RECEIVED BY DATE PERMIT NO. +.EH14-24iREV.iixsl EH 14-2e