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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT +� r 1601 E. HAZEL T ON AVE., STOCKTON, CA Q�J Telephone (209) 466-6781 AUG PERMIT EXPIRES TYEAR FROM DATE ISSUED � (Complete in Triplicate) ENVIRCM��TAI- HEALTH P p FERMIT/SERVICES f 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/pump and the Rules and Regulations of the San Joaquin Local Health ��Diis/s''trri�ictt./. Job Address T✓�'7rCz - Cites Lot Size PM Owner's Name Address _ C - " „-.., Phone Contraclar > rh Address License Nva 762 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION X SYSTEM REPAIR ❑ OTHER ❑ 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 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack `� ❑ Tracy Type of Casing Specifications F1 Public Ll Other n Delta J Depth of Grout Seal Type of Grout - I Irrigation __Approxi Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. i/�_ State Work Done c Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth I Filter Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION la REPAIR/ADDITION I 1 DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial` Other Number of living units: Number of bedrooms T Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ I L Method of Disposal Distance to nearest: Well 7_F ndation Property Line I LEACHING LINE ❑ No. & Leri Length of lines "s',��"°° """`" 9 —'Total-length/Size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance Distance to nearest: Well _ Foundation Property Line i DISPOSAL PONDS ❑ � iF 1 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 thelfollowing: "I certify thai 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,1 shall employ persons subject to workman's compensa- tion laws of California." I The applicant f for all required " spections. Complete drawing on re arse side. Signed Title: Date: FOR DEPARTMENT USE ONLY 1 Application Accepted by Date Area Pit or Grout Inspection by Date_ Final Inspection by Date ` _ Ora' i Additional Comments:. ► 4 ❑ Stk 465-6781 ❑ Lodi 359-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6365 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O- Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY PATE PERMIT'NO. r EH 1124 1REV,r/H 5) 35 Po EH 4-26 y�,