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APPLICATION FOR PERMIT g, n SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE i ON AVE., STOCKTON, CA Telephone (209) 466-6781 . PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for wail/pump and the Rules and Regulations of the San Joaquin Local Health District. J f. Joh Address ! ") ! ��^ �` " z)Cit 40 9Aot.Size162 11 X ``. t ! frs _ OfO Phone- 1r` Owner's Nam Address. Contracto Addres c License J Phone,�� l TYPE OF WELL/PUMP: NEW WELL @ WELL REPLACEMENT,❑ DESTRUCTION ❑ f PUMP INSTALLATI N SYSTEM REPAIR ❑ : OTHER ❑ _ DISTANCE TO NEAREST: SEPTIC TANK a SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS w F,_ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIDN . fl ❑ Industrial Mg 65en Bottom ❑ Manteca Dia. of Well Excavatio Dia. of Well Casing , �riestic/Private 1-1GravelPack LJ Tracy Type of Casing Specifications FI Public rl Other F1 Delta Depth of Grout Seat Type of out t I i Irrigation _..Approx. Dept l I Eastern urface Seal Installed by - Repair Work Done ❑ Type of Pump I c H.P. �� 1 State Work Done Well Destruction ❑ Well Diameter Sealing Material atop 501 ` Depth Filler Material IBelow 50') �1V TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION I l DESTRUCTION 1 1 .(No septic system permitted if public sewer is f available within 200 feet.i } 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. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line - SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line A DISPOSAL PONDS ❑ { 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 mu call for all required inspections. om late drawing on reverse side. �+ I Signed X ��- - Title: Date: ) FOR DEPARTMENT USE-ONLY l i Application Accepted.by Date r r� Area Pit or Grout Inspecti by Dat Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 - FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT NO. INFO . EH 14-241REV.I/K51 EH -26 : r.