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APPLICATION FOR PERMIT S SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Y Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED b } (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct andlor install the work herein described. This application is made in compliance with San Joaquin Co linty Ordinance No.549 for sewage or No. 1862 for welltpump and the Rules and Regulations of the San Joaquin Local Health District. a Cit of Size PM Job Address ' � Address, � — Phone 's Name Ownert r Contractor Address License No. Phone TYPE OF-DF P: Y NEW WELL ❑ WELL REPLACEMENT ❑ DESTRU i PUMP INSTALLATION LlSYSTEM REPAIR ❑ O H DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PIT5ISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS \ ❑ ri Industal L1 open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Type of CasingSpecifications El — ' Domestic/Private ❑ Gravel Pack C3 Tracy M Public F-1 Other C7 Delta Depth of Grout Seal Type of Grout { 1 IrrigationApprox.�Depth l I Eastern Surface Seal Installed by Repair Work Done E] Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material )top 501 - Depth Filler Material IBelow 50`) 71nsiallation EPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION Ah available No rw chin 200 feet.)c system r. ed iF public sewerlis will serve: Residence A Commercial— Other of living units: Number of bedrooms rWater table depthr of soil to a depth of 3 feet: g Capacity No. Compartments SEPTIC TANK ❑. Type/Mf LT. ❑ Method of Disposal PKC. TREATMENT P �. Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines " Total fengthlsize FILTER BED ❑ Distance to nearest:' Well Foundation Property Line J ._ r Number SEEPAGE PITS Depth � r Size ' — µ ? SUMPS Cl istance.to nearest:,p Well Foundation Property Line _ F DISPOSAL PONDS ❑ •` 7 _ —� �i�.. ff I.li'tr��'-� `I he7eby certify that I have prepared this application and that the bork will be done`in ccordance,w` h San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Dr"strict. 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." I The applica ust call for all required ins ions. Complete drawing on r rse side. /D Jja Signed Title: . Date:/ I �r FOR DEPARTMENT USE ONLY Application Accepted by _— Date Area Pit or Grout inspection by Date Final inspection by y Date Ire 1. C L • Lam[ C S .20 Additional Comments: ❑ Stk 466-6781 El Lodi 369.3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO = t L `a! i ♦.EH 13-24 IREV,I/K 5rS•' f EH 14-25