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r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. [1 ' Jab Address City Lot Size PM Owner's Name Address Phone l , Contractor �"` Address J�p A) License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR [I OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS f INTENDED USE TYPE;OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom Q Manteca Dia. of Well Excavation Dia- of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications N F] Public n Other {1 Delta Depth of Grout Seal _ _ Type of Grout I I Irrigation _..Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of;Pump H.P. State Work done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') 3 Depth ' Filler Material (Below 50'1 + TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION (No septic system permitted if public sewer is vailable within 200 feet.) Installation will serve: Residence_ Commercial S_ Other Number of living units: Number of bedrooms ' 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 ❑r No. & Length of lines• Total length/size FILTER BED ❑ Distance to nearest: SWelIFoundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Cl 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 ' ense I agent's signature certifies the following: "!certify that in the performance of the work for which this permit is issued, l shall not F employ any pe o uch neer as to become subject to workman's compensation laws.of California." Contractor's hiring or sub-contracting signature certifies the f low : "I a fy 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 lif is " The applican 1 quired inspections. Complete drawing on reverse side. Signed X Title: Date: j F �PARTM�ENTSE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date/ ..,� Additional Comments- ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ anteca 823-7104 ❑ Tracy 835-6385 I Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 35201 FEE AMOUNT DUE CK INFO AMOUNT REMITTED 'RECEIVED 6Y DATE PERMIT'N0. r EH 13-241REV.t/R5) �� / EH 14.29 - /]/ / ("� - QC J