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APPLICATION FOR PERMIT r r1 SAN JOAQUIN LOCAL HEALTH DISTRICT 1 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) 'k 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. L Job Address Cit C- of Size PM r Owner's Nam Address Phon ey��xlll 19 _..._ Contracto.. Ad r ss ;License No. T _ Phone r TYPE OF WELL/PUMR NEW WELL ❑ WELL REPLACEMENT ❑ .,,DESTRUCTION ❑ PUMP INSTALLATION ❑_ __SYSTEM REPAIR ❑ _ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK . r SEWER LINES x DISPOSAL FLD. ._ PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL ` PIS S/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTR CTION-SP CE IFICATIONS ❑ Industrial L3 Open Bottom ❑ Manteca ia:of Well Excavation Dia. of Well Casing ❑ Domestic/Private D Gravel Pack - cy-- - Type of Casing - Specifications [7 Public 1 1 Other _ ❑ Delta ,' .Depth of Grout Seal ! Type of Grout I I Irrigation pprox. Depth 11 Eastern` Surface Seal Installed by _ Repair Work Do Type of Pump I H.P. State Work Done I Well ction FY Well Diameter -Sealing,Maten l (top-50'1 ' Depth Filler Material (Below 50') n TYPE OF SEPTIC WORK: NEW INSTALLATION I] j REPAIR/ADDITION [ I DESTRUCTIO I (No septic system permitted if public sewer is V ! t available within 200 feet.I 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 r SEPTIC TANK Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal 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 11 Depth Size Number 1 SUMPS Cl Distance to nearest: Well Foundation Property Line l 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 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 campensa- tion laws of California." The a licam mu II for 11 re ui ed inspecti Complet drawing an r r e side. Signed X r Tit `+ � R DEPARTMOT USE ONLY �a-� Application Accepted by Date G" Area Pit or Grout Inspection Date Final Inspection by e27 Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manta823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT'NO. y a EH 13-24(REV.I/ns) �� aq,, i EH 14-26