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APPLICATION FOR PERMIT SAN JOAaUW LOCAL HEALTH DISTRICT Nt7 1601 E. HAZEL T ON AVE., STOCKTON, CA + Telephone 12091 466-6781 N p�, 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 1 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 t Local Health District ^ I r , i'T t 1 City Kkdt'ot Size PM V. Job Address / a Owner's Name Address _�/+/1� Phone i �+ { Address L.icense'No. Phone Contractor •� �� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PS FOUNDATION AGRICULTURE WELL OTHER WELL i {k INTENDED'USE TYPE OF WELL PROBLEM AREA CONSTRUCTION 5P ONS Dia. of Well Casing L] Industrial Ll Open Bottom EJ Manteca Dia. xcavation Specifications ❑ Domestic/Private ❑ Gravel Pack [5Spec Tracy Type of Casing i 11 Public ❑ Other elta Depth of Grout Seal Type of Grout q ❑ Irrigation ---A epth Ll Eastern Surface Seal Installed by Repair Work Done ❑ pe of Pump H P. State Work Done_ 1 Well Destructi ❑ Well Diameter Sealing Material (top 501 e — d Depth L —Ei11er_Material.(Below 50'.) ,E -- - - TYPE OF SEPTIC WORK: '•NEW INSTALLATION EDI REPAIR/ADDITION ❑t DESTRUCTION aNailable'within 200 feetitted if piiublic sewer is ..R �.-. k� Installation will serve: Residence Commercial— Other _ l Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth Capacity No. Compartments I " SEPTIC TANK VA Si., Type/Mig �.. o E Method of Disposal PKG. TREATMENT PLT.'❑T"• rI lI I I g " Distance to nearest: ? Well Foundation Property Line ' rI ` Total length/size ^ LEACHING LINE D No. & Length of lines'``" FILTER BED Cl Distance to nearest: Well Foundation Property Line SEEPAGE PITS F1Depth 1'1 Size Number SUMPS ❑ Distance!to nearest: Well Foundation Property Line lily DISPOSAL PONDS ❑' I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinanl es, 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, V 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 wof rkman's compe6sa- tion laws of California." The applicant must call for all required inspections. Complete r wing on reverse side. m r _ Date: OR DEPARTMENT USE ONLY e 1SI Date Area Application Accepted by +► '` y� Pit or Grout Inspection by Date 'Final Inspectipn by i Date � 1 wel Additional Comments: E'er � ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Mar{aca 823 7104 ❑ Tracy 63 6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 } FEE ffiME;TEEPERMIT N0. t INFO AMOUNT DUE AMOUNT REMITTEDQ+ EH 13-24(REV.t 7 k 5) � � �O � EH 14-28 L -•— ' - .. — M s