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I 3 iJ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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 Local Health District. for well/pump and the Rules and Regulations of the San Joaquin r, } Job Address �� / � � Ci Lot Size PM Owner's NameAddressor Phone ' J �4 7 Contractor's Name � te;� License No. TYPE OF WELL/PUMP: Phone -- NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWERILINES 11 DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation O Domestic/Private F] Gravel Pack El Trac , Dia. of Well Casing 1 1 Y ; Type of Casing -...-"�"°�T,'. — ^^,®,;'�'.��..... - ifications 11 Public ❑ Other ❑ Spec Delta Depth of:Grout Sea! El Irrigation Type of Grout J Approx. Depth ❑ Eastern Surface Sea! Installed by f Repair Work Done ❑ Type of Pump H P State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 5011 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is I Installation will serve: Residence_ Commercial_ Other �available within 200 feet.l Number of living units: Number of bedrooms :3 � f .) Character of soil to a depth of 3 feet: SEPTIC TANKWater table depth f0 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. El Method of Disposal Distance to nearest: Well` Foundation �op'erty Line LEACHING LINE No. & Length of lines T6tai lerigth/size FILTER BED ❑ Distance to nearest: Well Irl . Foundation, Property Line SEEPAGE PITS ❑ Depth -.2- 14 Size TM Number SUMPS 5V4 Distance to nearest: Well Foundation DISPOSAL PONDS F1 — Property Line- 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, !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 must call for all required inspections. Complete drawing on reverse side. Signed)L. Title: Date: mfr - g DEPART T USE ONLY Application Accepted by Date - Area Pit or Grout Inspection by Date Final Inspection by Datel Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 11 Tracy 835-6385 E 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# > INFO CASH RECEIVED BY DATE PERMIT`N0. +EH 1324(REv.10183) �S, ^EH 14 !28. , s�