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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT —.4 1601 E. HAZELTON AVE., STOCKTON, CA 5 Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) r 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 a Local Health District.'!'-` C� ' vlsAq N1 Joh Address o- City n4 f Size r i Owner's Name" Address ` Phone ContractorI Address r , nse No. Phone 'l 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 FOUNDATION AGRICULTURE WELL OTHER WELL t PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA GONSTRUCTlON SPECIFICATIONS ❑ Industrial "r p Open'Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gr'avel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal 'f Type of Grout ❑ Irrigation _Approx-Depth--.-❑-Eastern Surface Seal Installed by 4-14Repair Work Done C1 Type of Pump ` H.P. _ State Work Done 1 Well Destruction ❑ Well diameter- "t0 Sealing Material (top 50'1 Depth Filler Material (Belo TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ INo septic system permitted if public sewer is ' �t'�`v"��--�^� _ _ avails within 200 feet.) Installation will serve: Residence Commercial Other Number of living units: Number of becknorn L: Character of soil to a depth of 3 feet:f ' '�' Water table depth SEPTIC TANK L Type/Mfg C-Pac'ityl:%(-M I 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 ❑ Depth Size Number .SUMPS ❑ Distance to nearest: Well Foundation Property Line 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 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 t' 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: "1 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 ca fo require ins pe tions. Complete wing o rse side. Signed Title: x, Date: I FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by t Date Final Inspection by Date A4ditional Comments: Stk 466-6781 13 Lodi 369-3621 EI Manteca 823-7104 ❑ Tracy - ` plicant- Return all copies to: Environmental Health Permit/Servioes 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEECK F INFO AMOUNT DUE 'r AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. a + EH 1 V.1/a 51 SH 14"264-28 . I