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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA N10 �+ 4 � � Telephone (209) 466-6781 `'�' PERMIT EXPIRES 1YEAR FROM DATE ISSUED �,"%4 j (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 i 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 4 e t LJobddress CitY Lot Size pryq�/s Name AddressPhonector Address Lic se No. Phone TYPE OF WELL/ MP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ "• DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES 1SP05AL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRU ION S FICATIONS # ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of ell Excavation 1 ❑ Domestic/Private ❑ Gravel Pack Dia. of Well Casing - ❑ Tracy Typ f Casing Specifications M Public 71 Other p C7 Delta Type of Grout I pth of Grout Seal i I Irrigation __Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H p State Work Done � I Well Destruction ❑ Well Diameter ealing Material {top 501 Depth Filler Material IBelow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l 1 DESTRUCTION r,4k(No septic system permitted if public sewer is Installation will serve: Residence_ Commercial— Other available within 200 feet.) Number of living units: Number of bedrooms a r Character of soil to a depth of 3 feet: SEPTIC TANK ❑ T I Water table depth Type/Mfg PKG. TREATMENT PLT. ❑ Capacity No. Compartments T , T Method of Disposal , Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines � Total length/size n FILTER BED ❑ Distance to earest: Well Foundation Property Line + I SEEPAGE PITS I I Depth I Size Number SUMPS LI Distance to dearest: Well Foundation DISPOSAL PONDS ❑ Property Line 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 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." Contractors 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 re fired 'nspections C plate drawing on r arse side. Signed X Title: ON i Date:49, OR QEPARTMENT USE ONLY .Application Accepted by Area.- Pit 4✓ Pit or Grout Inspection by Date Final Inspection by Data Additional Comments: _40 ❑ Stk 466-6781 ❑ Lodi -3621 1 ❑ Manteca 823-7104 ❑ Tracy'835-6385 ;Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i FEE AMOUNT DUE AMOUNT REMITTED CK INFO CASH RECEIVED BY DATE PERMIT NO. a EH114-2a3-24(REV.tiny 2 EH j _