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N APPLICATION,FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA y �� 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 and Regulations of the San Joaquin Local Health District. ' Job Address LUJ City - Lot Size PM Owner's Name ddress Phone Contractor L License No. hone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL-REPLACEMENT DESTRUCTIO PUMP-INSTALLATION--❑-��'�'� –'' --4 SYSTEM REPAIR-fl- `�—OTHEfi W 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 t - r ❑ Public ❑ Other © Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. ` State Work Done Y W t Well Destruction ❑ Well Diameter Sealing Material {top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION❑ DESTRUCTION IND septic system permitted if public sewer is vailable within 200 feet.) 3 f Installation will serve: Residence Commercial— Other y Number of living units: Number of bedrooms ; Water table depth Character of soil to a depth of 3 feet:-�s i SEPTIC TANK ❑ Type/Mfg: -Capacity No. Compartments II i I t i PKG. TREATMENT PLT. ❑ .� Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line ' ` F , SEEPAGE PITS Q Depth "I Size Number r a SUMPS ❑ Distance to nearest Well foundation Property Line i 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. NZ 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 applicant must call for all required inspections. Complete drawing on reverse side. : 10 L Title: Date: Signed XJP t FOR EPARTMENT USE ONLY Application Accepted by Date �S� Area Pit or Grout Inspection by Date Final Inspection ' Datef6 dditional comments 17 i Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 A'plicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT O E AMOUNT REMITTED A RECEIVED BY DATE PERMIT NO. INFO + EH 13-24(REV. 17--1, EH 14-28