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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CAf Telephone (209) 466-6781 t f•6 J� �s PERMIT EXPIRES 1'YEAR FROM DATE ISSUED4 ! O � (Complete in Triplicate) APR 6 199 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install j�ypoork,herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and tfle Pi%A" I tions of the San Joaquin Local Health District, PER41T/$��HEALTH,Dtf i � t r Job Address City Lot Size PM Owner's Name a��'R Address Phone Contractor Address License No. _PhorrC�`�� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT El DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. 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 ("1 Public ❑ Otherx_ ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation _.-Approx. Depth l I Eastern Surface Seal Installed by t Repair Work Done ❑ } Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 X Depth Filler-Material (Below 50-)r TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION l 1 (No septic system permitted if public sewer is . available within 200 feet.) U Installation will server Residence# Commercial_ Other Number of living units: -I— Number of bedroomsss Character of soil to a depth of 3 feet: Water table depth 0 SEPTIC TANK ❑ Type/Mfg � �!� -� Capacity 42 No. Compartments PKG. TREATMENT PLT"❑ ! Method of Disposal W 4y Distance to nearest: Well Foundation Property.Line-2 D � LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ..❑ Distance to nearest _ Well Foundation Property Line.."..�d i SEEPAGE PITS I I Depth"o Size" -Number. SUMPS ❑ Distance to nearest: Well—, Foundation Property Line DISPOSAL PONDS El ' r Zl S .� r hereby certify that I have prepared this application and that the work wilt 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."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 muirrWil for all regwr rnspe tions. Complete drawing on reverse side. d Signed X___ Title: Date: M r FOR_DEPARTMENT USE ONLY Application Accepted I I Date p Area 2 C/ Pit or Grout Inspection by �^ Date Final Inspection by Date 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 s� INFO FEE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY PATE PERMIT-NO. +.EH 14-21[REV.f i H 51 _7,z, EH 11-28