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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE„ STOCKTON, CA Telephone (209) 466-6781 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 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. [� ` l Job Address / "'�� A City Lot Sizes P� M Owner's Name Address ,AJJn e Phone Contractor's Name_- Lzz_ \& LxLlieense No. �i~ `_.,_._._ Phone TYPE OF WELL/PUMP: NEW WELL q 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other © Delta 1Depth of;Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern /Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. I } State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth ! Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION V PESfRUCTION ❑ (No septic system permitted if public sewer is r+ l available within 200 feet./ Installation will serve: Residence UCommercial_ Other _Number of living units:-I--- I Number olhedrooms Character of soil to a depth of 3 feet: _ E�X§ T Water table depth y SEPTIC TANK ❑ Type/Mfg Capacity--L- No. Compartments Q l PKG. TREATMENT PLT. ❑ ` i ' Method of Disposal Distance to nearest: ,Well Foundation' Property Line ` (LEACHING LINE li-�3�a i& Length of lines ��,, �� Total length/size FILTER'BED ❑ Distance to nearest: 'Well!_ Foundation Property'Line SEEPAGE PITS ❑-Depth "d`-fir Size I Number _S_UMPS_ ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 whichthis 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-coritracting signature certifies the following:"I c 'fy that in the pe ormance of the work for which this permit is issued, I shall employ persons.subject to workman's compensa- tion a f California." { The applican call for all equi inspe ons. mp a drawing o verse side. Signe Title: ._ Date: FOR DEPARTMENT USE ONLY Application Accepted by Cf Date yArea f rtor Grout inspectio n-by --- Date_. _ ation Additional -.f ❑ Stk 466-6781 ❑ Lodi 369-3821 ❑ Manteca 823-7104' ❑ Tracy 835-6385 ,Ir 520 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9 �/.�V INFO AMOUNT DUE AMOUNT REMITTED CAWC RECEIVED BYFEE _T DATE PERMIT140. + EH 1241REV.10(631 EH 14126 t