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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 they 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. (� I Joh Address /� / lam, �/U / Cit Lot Size �.,. � PM Owner's Name Address f one Contract r G' ( Addressy (7/ License No. Phone Sl�] TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ! DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing f ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Fl Public - f l Other-- - 17.1 Delta Depth of Grout Seal . Type_of. Grout I I Irrigation —Approx. Depth f I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P.' _ State Work Done_ Well Destruction ❑ Well Diameter Seali'rig Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR1ADOITION I-]"DESTRUCTION I-I (No septic system permitted if public sewer i,_ f available within 200 feet.► Installation will serve: Residence_ Commercial� Other i Number,of living:units: J Number of dooms..._I Character.�of.soli to aFdepth,of 3 feet: Water table depth SEPTIC TANK Type/Mfg I �3'LAt e� Capacity No. Compartments PKG. TREATMENT PLT. ❑ / Method of Disposal y Distance to nearest: Well�,� _ _ Foundation .._.._. Property Line k. LEACHING LINE >� No. & Length of lines. _ Total length/size x SI- FILTER BED D Distance to nearest: WeFoundation tial Property Line oli- '�- SEEPAGE SITS Depth Size Number 'SUMPS ',`„ r ❑ Distance to nearest: Well t —S [L_ Foundation �? Property Line '.._ DISPOSAL PONDS ❑ I hereby certify that I have prepared this application.and.that the work will be don-6 in accordance with San.Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. /i Horne 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 asv become subject to work ma n's,com6e6sation laws of California." Contractor's hiring or sub-contracting signature certifie's the following:"I certify that iri'ttielperformance of the work fol which this permit is issued,'l shall employ persons subject to workman's compansa tion laws of California." i The applicant st call for =dinspectiofis.,Complete drawing on reverse_ side.'` Signed X Title:, V� —--. Data: ` 4 FOR DEPARTMENT USE ONLY � r t Application Accepted by �- Date gy I ` Area •; - x ell it r Grout Inspection by DateJFinal Inspection by� a.t� Date Additional Comments: o ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-71041 0:Tracy 835-6365 Applicant- Return all copies to: Environmental Health Permit/Services '1601 E. Hazefton Ave:,-P.O:'-Box 2009,-Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. +.EH 13-24(REV EH 14-2e I`� • 0 ( ) i