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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 welltpump and the Rules and Regulations of the San Joaquin Local Health District. City ,shat LotSize 'J Owner's Name �� Address. o� Phone Contractor Address License [Vo. Phone r TYPE OF WELL/PUMP: EW WELL WELL REPLACEMENT M DESTRUCTION"❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK- 11 — SEWER LINES DISPOSAL FLD. PROP. LINE; -, FOUNDATION AGRICULTURE WELL .cls OTHER WELL PITS/SUMPS Z_W INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' LJIndustrial ❑ Open Bottom ❑ Manteca Dia..of Well Excavation Dia. of Well Casing XbomesticIPrivate gGravel Pack ❑ Tracy Type of Casing J00 —_ Specifications FI Public cin Other F1 Delta Depth of Grout Seal �� Type of Grout I I Irrigation ,i Y_a.fApprox. Depth I I Eastern Surface Seal Installed by .2/31n=9 - Repair Work Done ❑ Type of Pump _.C_4 H.P. J — State Work`Done — S Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') -- S TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I I DESTRUCTION [ I (No septic system_ permitted if publicsewer is Installation will serve. Residence_ Commercial_ Other d 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. Compartmentsz" y 4 PKG. TREATMENT PLT. ❑ ,,� Method of Disposal ' Distance to nearest: Well Foundation Property Line a. LEACHING LINE ❑ No. & Length of lines" Total length/size r FILTER BED ❑ Distance to nearest:. Well Foundation Property Line SEEPAGE PITS I'I Depth .i 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 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 cal If II required i spectio A 14,r pl drawing on reverse side. Signed X Title: Date: a FOR DEPARTMEN USE ONLY Application Accepted by Date Area Pit or rout nspec71 tion — Data- '�s Final Inspection by Datei Additional Comments: ❑ Stk 466-6781 ❑ 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 BY DATE PERMIT'NO. INFO CASH i.EH 13-241REV.lix al EH 14-2e