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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1 1601 E. HAZELTON AVE.,:STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES I 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. ,J Job Address City Lot Size PM Owner's Named [JCT[_' �_'Address J V/C _- _ Phone - a Contractor A Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ ' 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 J 1 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy 'Type of Casing Specifications ❑ 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_ (� Well Destruction ❑ Well Diameter F Sealing Material Itop 501I UJ1 Depth I Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑' DESTRUCTION QP41 No septic system permitted if public sewer is ailable within 200 feet.) Installation will serve: Residence Commercial— Other - Number of living units: � Number of bedrooms Character of soil to a depth of 3 feet:, ' Water table depth SEPTIC TANK Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. LJ of Disposal Distance to nearest: Well Foundation .Property Line LEACHING LINE ❑' No. & Length of lines Total length/size FILTER BED ❑i. Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑'! Depth y Size Number SUMPS Q< .Distance to nearest: Well - Foundation Property Line. DISPOSAL PONDS ❑ " r 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. 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 ust tail for all requir ctions. Complete drawing on reverse side. Signed Title: w a w v Date: x.� FOR DEPARTMENT USE ONLY a Application Accepted by Date Area Pit or Grout Inspection t Dat ` Final-Inspection by CS~t�`� Date �. a \ r Additional Comment ❑ Stk 466-6781 Lodi 69-3621 ❑ Man ca -7104 ❑ Tracy 635-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.,.P.O. Box 2009, Stkt, CA 95201 FEEt INFO` AMOUNT DUE I� AMOUNT REMITTED CASH RECEIVED BY DATE PER NO. + EH 13-24(REV.I/N5) } �� U� S1 .• '� ��' 1 —)021 r EH 14.26 L---- z