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k APPLICATION FOR PERMIT ` SAN JOAQUIN LOCAL HEALTH DISTRICT f 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 welUpump and the Rules and Regulations of the San Joaquin Local Health District, Job Address . D � r✓ �C/ �� U�� 7,piret City Lot Size PM Owner's Name /r �� 'f Address £irC�iC ! Phonep f Contractor r 5 dress cense No. f► / Phone TYPE OF WELL/PUMP: NE WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIp PUMP INSTALLATION C1SYSTEM REPAIR ❑ (2) 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 M Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F1 Public ❑ Other Cl Delta Depth of Grout Seal Tye of Grout i I Irrigation __.Approx. Depth l I Eastern Surface Seal Installed by �� _ Repair Work Done ❑ Type of Pump t H,P. State Work Done +�/� Well Destruction N Well Diameter A 91 Sealing Material (top 501 Depth rA 60/ Filler Material (Below 50'I TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I I DESTRUCTION I ) iNo septic system permitted if public sewer is available within 200 feet.) 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 Q SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal c Distance to nearest: Well Foundation Property.Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 Diltrict. 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 taws of California." Contractor's P ont attar'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 applicant�red ins Qpmplete drawing on z2revers-- e side. Signed tle: !� pate: FORIEPARTMENT USE ONLY �) Application Accepted by &o_� �.�I.�iAn�fl. bate J e Pit or Grout Inspection by Date Final Inspection by Dat��w Additional Comments: ❑ Stk 456-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY jDATE PERIhMIT'NO, + EH 1 -24 1 REV.5/li 5 f � /'U� I J�(/ 1 EH 114-26 it l./ L 1 (�f