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r APPLICATION FOR PERMIT y`y V� 7 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 `T b T 6 } PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �� n 'r (Complete in Triplicate) i. 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 i Local Health District. CitV, Lot Size PM Job Address Owner's NameAddress Phone �Contractor Address License No. Phone TYPE OF WELL/PUMP.. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP,INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER El 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 ❑ Industrial LJ Open Bottom C] Manteca Dia. of Well Excavation r Dia. of Well Casing Type of Casing p Specifications (,� C C1 Domestic/Private ED Gravel Pack ❑ Tracy 9 l'1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Gra r h—� I 1 Irrigation �_Approx. Depth 1.1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Weil Diameter _ Sealing Material (top50T 1 Depth, Filler Material (Below 501 t TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I.I DESTRUCTION l 1 (No septic system permitted if public sewer is I 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 d PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest:' Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size , FILTER BED ❑ Distance to nearest:' Well Foundation Property Line SEEPAGE PITS l 1, Depth Size _ Number i SUMPS Ll Distance to nearest: Well Foundation ` Property Line i DISPOSAL PONDS ❑ d . I hereby certify that k have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, 0 rules and regulations of the San Joaquin Local Health Di3trict. 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�pp7FA� a! quired inspections. Complete drawing on rra arse side. Cf/f/�� Title: V Date: t/� Sign .j: FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit of Grout Inspectio y Date Final Inspection by Date f' Additional Comments: (✓C l v c L o4' U ❑ S 466-6781 ❑ Lodi 369-3t2l ❑ 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 !KJ RECEIVED 9YDATE PERMIT'NAMOUNT DUE AMOUNT REMITTEDEH 1324; Ev.riR5) 3. 0 °t EH 14-26