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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 i 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. . Job Address City Lot Size PM Owner's Name ddress Phone Contractor lZir, Address License Ne/6 Phone' TYPE OF WELL/PUMP: NEW WELL ❑ A WELL REPLACEMENT ❑ DESTRUCTION Ef 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 Well Casing ❑ Domestic/Private I] Gravel'Pack- -- [J-Tracy —Type-of CasingSpecifications i'1 Public F1Other F1Delta Depth of Grout Seal t Type of Grout _ I 1 Irrigation —_ApproxDepth l I Eastern Surface Seal Installed by _ I Repair Work Done ❑ Type of Pump ;: y;p. State Work Done_ Well Destruction El Well Diameter F TSealing Material (top 50') ' Depth # a Filler-Material {Below '1 -TYPE OF SEPTIC WORK; NEW INSTALLATION [I REPAIR/ADDITION DESTRUCTION i I (No septic system permitted if public sewer is available within 200.feet.) Installation will serve: Residence Commercial Other °b �.. 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. ❑ - }} i Method of Disposal Distance to nearest: (Nell Foundation Property.Line LEACHING UNE ❑ No. & Length of lines Total length/size A4 12 FILTER BED ❑ Distance to nearest: Well iFoundation _ * Property Line EPAGE PITS i I Depth Size Nymber SU Ll Distance to nearest: Well Foundation Foundation Property Line DISPOSAL PONDS Cl 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 F 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 foilowing: "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 uired inspections 7 Complete drawing o arse side. Signed .I Title: Dat , [1� FOR DEPARTMENT.USE ONLY Application Accepted by VK�. L� -- _g Date Area Pit or Grout Inspection Data Final Inspection by Date ®� Additional Comments: ) t 3 ❑ Stk 466-6781 Q Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED l3Y INFO CASH DATE PER III NO. +.EH 13-21(REV. /H 51 Jin V, - EH 10-29 - / �f'� �Y