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Y APPLICATION FOR PERMIT SAN JOAO.UIN`LOCAL HEALTH DISTRICT 1601 E. HAZEL—1 ON AVE., STOCKTON, CA Telephone (209) 466-6781 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. 1862 for well/pump and the Rules amend^Regula ns a an Joaquin Local Health District. Job Address y. City 1 Lot Sizer' PM i Own is Name Address= — 'Phone r Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT D DESTRUCTION PUMP INSTALLATION ❑ I 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 I r'II Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other i} ❑ Delta Depth of Grout Seal Type of Grout ❑ irrigation ---Approx. 'Depth , ❑ Eastern Surface Seal Installed by Repair Work Done C1 Type of Pump 4 H .P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 1 i Depth + Filler Material IBelow 501-s TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION7>TiNo septic system permitted if public sewer is available within 200 feet.) Ir Installation will serve: Residence Commercial_ Other Number of living units: A_ Number of bedrooms y Character of soil to a depth of 3 feet: ' t —^' Water table depth SEPTIC TANK ❑ Type/Mfg1 Capacity No. Compartments [[. PKG. TREATMENT'PLT. ❑ ! - Method of Disposal Distance xo nearest: Well Foundation Property Line # LEACHING LINE ❑ No. & Length of lines Total length/size b FILTER BED ❑ Distance{to nearest: Well Foundation `Property Line SEEPAGE PITS ❑ Depth iJ '- Size Number SUMPS ❑ Distance to nearest:! Well Foundation Property Line DISPOSAL PONDS ❑ t 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.r I 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;he work for•which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California, The applicant must call far all required ins ctions. Compl to dTv) ing on reverse side: - . s r Signed T le. Date: FOR DEPA MENT USE ONLY T Application Accepted by � i DateIle Pit 3or Grout Inspection by Date h` Final Inspection by w" Date itional Comments: N"`' = -tv&. tk 466-6781 ❑ Lodi 362 ❑ anteca 823-7104 D Tracy 815:6M.()_. App nt- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT Dy E AMOUNT REMITTED CK RECEIVED BY ; DATE PERMIT`NO. INFO.. -- - CASH t*. wLL—rL 1(Cy6 k + EH 13-24('REV.1/0 5) + �""� '4" 3 221 EH 14-26