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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT T�� 1601 E. HAZELTON AVE., STOCKTON, CA i 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 Ryles and Regulations of the San Joaquin Local Health District. Y- f� Job Address QU r' City �_ I'� Lot Size PM Owner's Name 'r" �ess Phone Contractor^� `�`�" � "`� Address / Z1 t�icense No, Phone TYPE OF WELL/PUMP: NEW WELL 9�! WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATI SYSTE E IF�❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK DISPOSAL PLO. PROP. LINE 3 FOUNDATION THER WELL PITS/SUMPS -- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ff ndustrial ❑ Open Bottom ❑ Manteca Dia. bf Well Excavati Dia. of Well Casing ❑ Domestic/Private 5?Gravel Pack ❑ Tracy's; Type of Casing s Specifications ❑ Public ❑ Other ❑ Delta , Depth of Grout Seal SZ� r Type of Grout ❑ Irrigation ---Approx. Depth U Eastern' Surface Seal Installed by E s t Repair Work Done 1:1 Type of Pump (H.P. State Work,Done Well Destruction ❑ Well Diameter £Sealing Material (top 501 Depth Filler Material (Below 50') I TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION❑' ":DESTRUCTION ❑ kNo septic system permitted if public sewer is ],available within 200 feet.) Installation will serve: Residence Commercial_ Other , s Number oft units: Number of bedrooms I Character of soil to a depth of 3 feet: --} Mater table depth SEPTIC TANK ❑� Type/MfgT l Capacity INo. Compartments PKG. TREATMENT PLT. ❑ !Method of Disposal ` Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No, & Length of lines Total length/size i FILTER BED s fi ❑ Distance to nearest: Well Foundation Property Line Y SEEPAGE PITS ❑ -Depth- = I Size Number 4 SUMPS ,0.,�Distance to nearest: Well Foundation ProLineLine € 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 Iicensed'agen-t'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." � w The applicant t c I for all required inspections. Complete drawing on reverse side. Signed X / title:-^ ✓' L Da FOTMENT USE ONLY Application Accepted by Date i Area 40 I Pit or Gut spection by ate/ Final Inspection by D e 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 CK RECEIVED BY DATE PERMiT`N0. INFO CASH + EN13-24(REV.i/a5) EH 14 26 uY—va