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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 for welllpump and the Rules and Regulations of the San Joaquin Local Health District. • City"-S ' Lot Size !/ ! P U PM Job Address t��/ Owner's-Name Address 7 T s� F�+� i G 't Phone Contractor Address 1 License No. Phone' TYPE OF WELL/PUMP „_, ,NEW WELL ❑- WELL REPLACEMENT ❑ , DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ; DISTANCE T0:NEAREST: SEPTIC TANK SEWER LINES `DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �C INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION'S PECIrl CATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications' M Public F Other _ 71Delta' Depth of Grout Seal1 Type of Grout r I ! irrigation �.Approx. Depth l I Eastern -r r Surface SealAnstalled by� _ r Repair Work Done ❑ Type of Pump H.P. State Work Done W Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK; NEW INSTALLATION I] -REPAIR/ADDITION I -DESTRUCTION INo septic system permitted if public sewer is , vailable 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 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ` PKG. TREATMENT PLT. ❑ r Method of Disposal, Distance to nearest: Well Foundation 1 Property.Line f LEACHING LINE ❑ No. & Length of lines Total length/size 3- FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ 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 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." The applicant must call for all required inspec ions. Complete drawing on revecM side. f Signed X Title: �� Date: I FOR DEPARTMENT USE ONLY Application Accepted by Date Area i Pit or Grout Inspection by /Date Final Inspection by ?l Date Additional Comments: l v14 ❑ Silk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 839-6385 ' Applicant- Return all copies to: Environmental Health Permit/Services 1601.E..Hazelton.Ave., P.O. Box 2009, Stk., CA 95201 t' FEE " INFO AMOUNT DUE MOUNT REMITTED CK RECEIVED BY DATE PEERMIT'N^O. *.EH13.24IREV.i/Rsi 10cm uc— tu4v? V {��?t�1 . EH 14-28