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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT AIN A DN � 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 SAN JOAQUIN LOCA, PERMIT EXPIRES 1 YEAR FROM DATE ISSUED HEALTH DISTRICT (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 l 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 i Local Health District. Job AddressCit / f y Lot Size �Q PM Owner's Name Phone Contractor's Name License No. Phone��- .z TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 13DESTRUCTION 11PUMP INSTALLATION El SYSTEM REPAIR OTHER ❑ ` DISTANCE TO NEAREST: SEPTIC TANK - SEWER LINES DISPOSAL FLD. PROP. LINE i x _ —FOUNDATION..- __ _ AGRICULTURE-WELL, OTHER WELL PITS/SUMPS'_ INTENDED USE TYPE OF WELL PROBLEM AR�,CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of'Well Excavation Dia. of Well Casing CY6omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other Ll Delta Depth of Grout Seal�j Type of Grout r,f El Irrigation --Approx. De th ❑ EasternSurface Seal Installed by x Repair Work Done ❑ Type of Pump ,t H.P. - State Wor1t Done , j y+ 1 Well Destruction 11 Well Diameter;, ._.._..5ealing Material (top 501 Depth Filler Material (Below 501 "TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within}200 feet.) Installation will serve: Residence! Commercial_ Othpr L Number of living units: _ W r'Nurnber-of bedrooms- - w �t Character of soil to a depth of 3 feet: Water table depth� C C1iE SEPTIC TANK Type/Mfg 1 Capacity No. Compartments tro I PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line # M LEACHING LINE ❑ No. & Length of lines I k Total length/size i FILTER BED ❑ Distance to nearest: Well i, E Foundation Property Line 1 l �$ s SEEPAGE PITS ❑ Depth Size 1' Number S SUMPS ❑ Distance to nearest: Well Foundation " Property Line- J DISPOSAL PONDS ❑ j 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 Iaws.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 parsons subject to workman's compensa- tion laws of Califor 'a." 1 The applicant m ca for al requ' inspections. omplete drawing on43pterse side. �: Signed X _ Date:5 5— •, � I FOR DEPARTMENT USE ONLY ' Application Accepted by Date Are d Pit or Grout Inspection by Date Final Inspection by Additional Comments: �f ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Retum all copies to: Environmental Health Permit/Services 1601 E. Hazetton Ave., P.O. Box 2009, Stk.,"CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH 13-24(REV,10163) Lis. O Q bMv S'� L EH 1426 1 i