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VA APPLfCATlON 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 for well/pump and the Rules and Regulations of the San Joaquin Local Health District.. t Job Address C:7.. L ` , CityLot Size PM Owner's Namddress Phone Contractor Address CS t License c� Pho TYPE OF WELL/PUMP: NEW WELL ❑. 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 Weil Casing r ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications e (`I Public ❑ Other a Cl Delta D rout Seal Type of Grout I I Irrigation ---Approx. Depth i I E Surface Seal Installed by _ �1 Repair Work Done ❑ Type of H.P. State Work Done _ Well Destruction ell Diameter Sealing-Material (top 50'1 Depth Filler Material (13,10,50'I YPE OF SEPTIC WORK: NEW INSTALLATION I.i REPAIR/ADDITION.I l DEST R U CTIONACCINo septic system permitted if public sewer is, i_ vailable within 200 feet-i Installation will serve: Residence `� Commercial T Other Number of living units: Number of bedrooms Character of soil to a'depth of 3 feet — ---- - Water table depth SEPTIUTANK �' ❑ Type/Mfg Capacity - No. Compartments PKG, TREATMENT PLT. ❑ 11 Method of Disposal Distance to nearest: Well ` Founda•tion Property Line LEACHING LINE ❑ No. & Length of lines jTotal length/size FILTER BED ❑. Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size Number SUMPS Ll Distance'``to nearest: Well Foundation Property Line t DISPOSAL PONDS 0 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."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." I, _ The applican Must call for all required insp ti ns. Complete drawing-on re Signed Title: "-_- Date: FOR"DEPARTMENT USE ONLY t J Application Accepted by DateV,, Area Pit or Grout Inspection4y Date Final Inspection by Date Additional Comments: /J 7 7 / Ca Stk .466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601.E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 �. I FEEMOUNT DUE k AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. INFO � J 1L 1-23L EH 14-2e zCU+ EH 13-24 IREV.i ii s1 s