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APPLICATION FOR PERMIT V k fJ/ SAN JOAQUIN LOCAL HEALTH DISTRICT r f 1601 E. HAZE 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 i 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. � r �3x( � Job Address City z��Lot Size PM Owner's Name b ? Address- Phone Contractor ddress r License Iia Phone (i TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ i DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL, OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ,, ❑ Industrial I] Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing _ Specifications T1 Public f1 Other Cl Delta Depth of Grout Seal Type of Grout I ] Irrigation —.Approx. Depth I ) Eastern Surface Seal Installed by .. Repair Work boor e, D Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material Itop 50') ` Depth Filler Material (Below 501 p TYPE OF SEPTIC WORK: NEW INSTALLATION IV REPAIR/ADDITION'I'I TDESTRUCTION9 } {No septic system permitted if public sewer is i r V' available within 200 feet.) Installation will serve:"Residence---L--Commercial - _-Other Number of living units: --L Number of bedrooms Character of soil to a depth of 3 feet: I Water table depth SEPTIC TANK, ❑ Type/Mfg Capacity` No. Compartments PKG. TREATMENT PLT. ❑ JMethod of Disposal Er .ar 1 F Distance to nearest: Well 1-_O 0 Foundation 0 Property Line — Y LEACHING LINE L-]: '-No. & Length of lines Totalr length/size FILTER BED Q Distance to nearest: Well"-0— Fouridatian Property Line. € t - SEEPAGE PITS I 1 Depth Size - Number± 5 MPS ❑ Distance to nearest: Well_J_�� t j �f]t a — DISPOSAL PONDS ❑ � Foundation Property Line 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 tules,and regulations of the San Joaquin Local Health District, IL Horne-owner or licensed agent's signature certifies the following: "I certthat in the performance of the work for which this permit is issued, I shall not employ any person in such manner aslo become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the partormance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The id aprawin plicant ust call f II required i ctions. Com I dg o eY rS8 se. I ` . Signed X Title: Date: f ` k FOR DEPARTMENT USE ONLY r R Y ! Application Acce ted b Date Area Pit or Grout Inspection by Date Final Inspection by--(f. �, Date `(�O Additional Comments: ❑ Stk 1466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 El Tracy 835-6385 J Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 96201 j F1 E AMOUNT DUE AMOUNT REMITTED CK = INFO CASH RECEIVED BY DATE PERMIT'NO. f�p y� o + EH 13-24 rs 5 1REY:;i1 EH 14-26 ! D / .! ` �1�`O( U -'vs F