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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT t !�+ 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 a 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 welt/p mp and the Rules and Regulations of the San Joaquin Local Health District. f C Job Address City/ Lot Size PM t Owner's Name Address Phone ~ l�Phone lY _ Contractor dress J __ __ License No.� Tz TYPE OF WELL/PUMP: NEW WELL 171 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ YST EPAIR ❑ OTHER ❑ .� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINE DISPOSAL FCD. PROP. LINE FOUNDATION AGRICULTU WELL OTHER-WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM ARE ONSTRUCTION SPECIFICATIONS Ela Industrial - ❑-Open Bottom- °��❑-Mantecia:-of-Well-Excavation Dia. of Well Casing 1-1 Domestic/Private ElGravel Pack ❑ Tracy Type of Casing Specifications ("1 Public (-IOther F1bel Depth of Grout Seal Type of Grout_—. I 1 Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done LJ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') — TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet) � v Installation will serve: Residence____ Commercial— Other 4 Number of living units: Number of bedroo s" Character of soil to a depth of 3 feet: - Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ —Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ 1 No. & Length of lines 15 U Total length size FILTER BED ❑ Distance to nearest: Well Foundation "f'ropi3rty Line 1 SEEPAGE PITS 1 1 Depth Size ber ti X SUMPS Ll Distance to riearesti Well `�""�' Foundation' Property Line DISPOSAL PONDS ❑ 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 Di§trict. 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 worl'for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicah ust ca` Wall requir inspections Complete drawing on reverse side. ? r Signed X Title: ��f Date: J F R RTMENT USE ONLY Q Application Accepted by Date �: ` Area sva+r� Pit or Grout Inspection by Date Final Inspection b Dated a Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 FEEAMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT-N0. 1 INFO Pi CASH ♦.EH 3-21REV.t/nsl 14 7o EH 2a