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r APPLIMTION FOR PERMIT €.I f SAN JOAQUIN LOCAL HEALTH DISTRICT it 1601 E. HAZELTON AVE., STOCKTON, CA E Telephone (209) 466-6781 % PERMIT EXPIRES i'YEAR FROM DATE ISSUED (Complete in Triplicate) €I 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. I� Job Address / Ci y Lot pSize PM Owner's Name a Address t Phone f Contractor License No. !I Phone S� I TYPE OF WELL/PUMP: NEW WEI L ❑ W MENT ❑ DESTRUCTION ❑ t PUMP INSTALLATION ❑ SYSTEM REPAIR D I�OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. li PROP. LINE l FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED*USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Pi 1 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing i ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Ii Specifications I Fl Public C1 Other ❑ Delta Depth of Grout Seal I, Type of Grout a I Irrigation —Approx. Depth t I Eastern Surface Seal Installed by �I _ Repair Work Done ❑ Type of Pump H.P. State Work Done_ \ Well Destruction ❑ Well Diameter Sealing Material (top 501 i� "{ I Depth Filler Material (Below 50') I� Nl�) TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION I! DESTRUCTION (No septic system permitted if public sewer is r available within 200 feet.i { Instal4ali n 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 1%°F ;- Capacity Nol�Compartments t ' PKG. TREATMENT PLT. ❑ i Method of Disposal t t 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 I Depth Size I Number Il I 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. If ! Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work lfor 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."Cont`ractor'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." nV ....The applicant ; ust call for It re uired inspections. Complete drawing on reverse side. I Signed XEbpTitle: ` �" � bate: FOR PARTMENT`USE ONLY Application Accepted by _ � r—S �g�y f�,,,�,��, Date — Area A �: f7 3� Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: 6 ❑ Stk 466-6781 ❑ Lodi 369-3621 Manteca 823-7104 ❑ Tracy 835-6385 !i Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 I EE INFO AMOUNT DUE AMOUNT REMITTED I CASH RECEIVED 6Y, 11DATE PERMIT'NO. + E"1 3-24(REV,I/Ati) — _ Q L 7 i7—,?y11 1 EH t4-26 1 dIA/ I A,/