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APPLICATION FOR PERMIT ` SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL 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 Locar Health District for a permit to construct and/or install the work 4heei escribed. 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 Loca>ealth District. Job Address Eck City Lot Size PM Owner's Name4 Address V i �w��c� Phone Contractor Address License No. Phone TYPE OF WELL/PUMP: _ w . . NEW WELL ❑ TMWELL REPLACEMENT ❑ M DESTRUCTION ❑ f PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DI SP L FLO. PROP. LINE FOUNDATION AGRICULTURE WELL HER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRU N SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. ell Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack----[]•-Tracy-- �-� ype of Casing Specifications F1 Public L-1 Other 17 Delta Depth of Grout Seal Type of Grout i I Irrigation �t.$pprox. Depth I 1 rnSurface Seal Installed by: Repair Work Done ❑ Type of Pump H.P. R State Work Done r . Well Destruction ❑ Weli Di am Sealing Material (top 501 t Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION l I DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) �~ k Installation will serve: Residence ti Commercial-- Other---, .� Number of living units: ' Number of bedrooms It Character of soil to a depth of 3 feet: 4 Water table depth SEPTIC TANK C. Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Qi. a Method of Disposal 1 Distance to neatest: Wel ufti-� Property tine tYPI LEACHING LINE ❑: N o, _ y Total length/size FILTER BED ❑ Di lance'to nearest- `JUyel t un Property Line ; Y idV + i SEEPAGE PITS I 1 Depth Number SUMPS L-1 DistaNs o nearest: Wel�� j alien Property Line DISPOSAL PONDS ❑ I hereby certify that..1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,-state laws, and, I rules and regulations of the San Joaquin Local Health District. I 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 j employ any person in such manner as to become subject to workman's compensatioA 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." i The applicant Riustt call,for all require spections. Complete drawing on reverse side. . Signed X ,C2& '�- /� Y Title: ,. ��G Date: �"j'� EPARTMENT USE ONLY r ^ �1 Application Accepted by 0 A .Date 4 fl'� )A"� � Area 4 Pit or Grout Inspection by Date .Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 0 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 RECEIVED BY DATE PERMIT NO. INFO 4TVASH + EH 13-24(REV.+i n s) I ��] I�] �-{/// EH 14-29 �� T /