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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT AG 2 � � 1601 E. HAZEL i ON AVE., STOCKTON, CA ENVIRONMENTAL HEALTH LY Telephone (209) 466-6781 PERMIT/SERVICES 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 made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address !?' CityI Lot Size PM . Owner's Name Address -�~ ' Phone Contractor Address ti `r a License N0�023P— Phone ^ TYPE OF WELLlPUMP: NEW WELL ❑ WELL REPLACEMENT © DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE .� : ._- - -. ;PIS/SUMPS FV0NDATION AGRICULTURE-WELL �_flTHERYW6LL INTENDED USE TYPE OF WELL - PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 1-1Open Bottom ❑ Manteca Dia. of Well Excavation 4 Dia. of Well Casing El Domestic/Private D Gravel Pack ❑ Tracy Type of_Casing Specifications ��..^. Public ❑ Other F1 Depth of Grout Seal Type of Grout I I Irrigation —Approx. Deptf-(,- I I Eastern ` Surface Seal Installed by Repair Work Done �Type of Pump H.P. �— State Work Done ; Well Destruction ❑ Well Diameter Sealing Material Stop 50'1 Depth Filler Material {Below 50') — TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION f I DESTRUCTION [ I (No septic system permitted if public sewer is available within 200 feet.) 1 Installation will serve: Residence_ Commercial_. Other " Y Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: v Water table depth I SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments i PKG. TREATMENT PLT. El 0 Method of Disposal Distance to nearest: Well Foundation Property Line r� i LEACHING LINE -❑ No. & Length of lines Total length/size FILTER BED - ❑ Distance-to-nearest:- -,Well---- — _---Foundation _ Property Line SEEPAGE PITS I I- Depth Size,-- Number r SUMPS Ll Distance to nearest: Well Foundation Property Line �DTSPUS-Ar-PONOS —E] ! hereby certify that t have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, a rules and regulations of the San Joaquin Local Health Di$trict. 1 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 applican I for all require inspections. Complete drawing on rerso Signed Title:' �� Date: g OR D ARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Data Final Inspection byA J_ Date 5 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 0 Manteca 823-7104 ❑ Tracy 835-6385 I� Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 I FEE AMOUNT DUE AMOUNT REMITTED SH RECEIVED BY DATE PERMIT'NO. 1 INFO _ r:EM 13-24(REV.r i n 5) Eli 14-26 }