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i APPLICATION FOR PERMIT \ 4 TEA SAN JOAQUIN LOCAL HEALTH DISTRICT �� 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED .(Complete in Triplicate) K e , ` i Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described,Ti n is i made in compliance with San Jolaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulatio 1u"I Joaquin Local Health District. t Job Address C City Lot Size PM Owner's Name Address Phone -Contractor .111 ddress LicYnse No. 4&2- Phon TYPE OF WELL/PUMP: I� NEW WELL ❑ WELL'REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR A, OTHER ❑ DISTANCE TO NEAREST: SEP'TIC-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 40mestic/Private ❑ Gravel Pack L1Tracy Type of Casing Specifications 4. F" Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I 1 Irrigation Approx. Depth I I Eastern Surface Seal Seal Installed by _ 011 Repair Work Done ()k- Type of P.ump _- H.P. I ��— State Work Done n Well Destruction ❑ Wel Diameter Sealing Material (top 501 "1 Depih Filler Material (Below 50') _ .r " `TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION I 1 DESTRUCTION I 1 INo septic system permitted if public sewer is III . available within 200 feet.) Installation will serve: Residence Commercial_ Other i Number of living units: �N Number of bedrooms �` }, Character ofisoil to a depth of 3 feet: Water table depth SEPTIC TANK:; ❑ Type/Mfg Capacity No. Compartments f PKG. TREATMENT PLT. ❑ �� • Method of Disposal k Distance ;-0--nearest: Well Foundation Property Line ' I G LEACHING LINE ❑ No. & Length of lines -- Total length/size I FILTER BED ❑ Distance to nearest: Well. Foundation Property Line SEEPAGE PITS l I Depth . Size _ Number �- SUMPS w v TM ❑ 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 DFstrict. 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 mu r 11 require .in ctions. Complete drawing on r verse side. - —-- - 'i 3 - � Signed Title: Date:( R DEPA TMENT USE ONLY—X4 . Application Accepted by Date v ✓ FArea r Pit or Grout Inspection by I Date Final Inspection by ate 9 t 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. Bax 2009, Silk., CA 95201 FEE CKf I� 'INFO AMOUkNT DUE AMOUNT REMITTED i CASH - RECEIVED BY DATE f�PErR.MIT NO. rEH 13-24 IREV.I/n5) _8 EH 14-26 I ( L I��