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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 m (Complete in Tripkicate) Application is hereby /ade to the an 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. 186 for well/pump and the Rules and Regulations�of the San Joaquin Local Health District. • � � Job Address City Lot Size PM ` Owner's Na Contractor Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATI.ON ❑ _ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK=z 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 r ❑ Domestic/Private . ,❑ Gravel Pack El Tracy Type of Casing Specifications F Public ❑ Other ' M Cl Delta Depth of Grout Seal Type of Grout--. l� I i Irrigation _.Approx. Dep�h I k Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump _. .3 H.P. State Work Done Well Destruction ❑ Well Diameters Sealing Material atop 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NFW iNSTAL-LAT-IGN�I.b REPAIR/ADDITION I I DESTRUCTION E (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial— Other Number of living units: t Number of bedrooms Character of soil to a depth of 3 feat; Water table depth SEPTIC TANK ❑ s Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ ` Method of Disposal 'Distance to nearest Well Foundation Property Line I LEACHING LINE 0� No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS III Depth Size Number SUMPS ❑ Distance oto nearest: Well Foundation Property Line' DISPOSAL PONDS ❑1 � 1 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 ORtrict. 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 tri become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature certifies the follawi j'I certify that in the performanc of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Can rnia/' The applica m cal quired' c rawing an reverse_Aide. SignedTitle: wy Date: �� ' FO EPARTMENT USE ONLY Application Accepted.6y. "—Date- Area- - Pit or Grout Inspection by Date Final Final Inspection byDate Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Enviro}mental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'r. . INFO CASH a,EH 13-24(REV.Iia 51 EH 14-26 c� 0