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APPLICATION FOR PERMIT " w SAN JOAQUIN LOCAL HEALTH DISTRICT - 1601 E.:HAZE T ON AVE., STOCKTON, CA ..ti. Telephone (209) 466-6781 PERMIT EXPIRES 'l 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. 11 I� b City, Lot Size PM Job Address O - ress Phone wner's Name _ . Phone Contractor's Name cense No. TYPE OF WELL/PU NEW WELL F] WELL REPLACEMENT ❑ DESTRUCTION El ,A if PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE E! FOUNDATION AGRICULTURE WELL - OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ) ❑(Industrial ❑ Open Bottom ❑ Man#eco Dia. of Well Excavation Dia. of Well Casing ❑bomestic/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 F , Repair Work Done ❑ Type of Pump H.P. State Work Done W611 Destruction ❑ Well Diameter Sealing Material (top 50'! I€ Depth Filler Material (Below ) �` TYPE OF SEPTIC WORK: NEW INSTALLATI N ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is ` i available within 200 feet.) Installation will serve: Residence Commercial Other r Number of living units: Number of bed oms �Q # Character of soil to a de h of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity x No. Compartments ' PKG. TREATMENT PLT. ❑ ( r Method of Dislposal Distance to nearest: Well Foundation d ' •Property Line .�- i fi .1 Totai lens th/sizeE ' lo LEACHING LINE No. & Length of lines ~' ° L g d �. FILTER BED ❑ Distance to nearest: Well/�� Foundation Property tinea - I , r SEEPAGE PITS Depth('..' Size— 3 Number SUMPS ❑ Distance to nearest: Well Foundation_i 0p Property Line 61SPOSALPONDS ❑ Thereby 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." 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." "b The applicant all require 'n ctions. Comp a drawing on rev side. II Title: –� Date: Signed FOR DEPARTMENT USE ONLY Area Application Application Accepted by Date Pit or Grout Inspection by Date Final Inspection by Date 4 I — Additional Comments: r "" i] Stk 466-Ml ❑ Lodi 3621 anteca 823-7144 ❑ Tracy, 835-6365 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK 4FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. dry g5 + EH 13-24[REV.101831 P _! EH 4.28 V .