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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL"HEALTH DISTRICT 1601 E. HAZE4TON'AVE., STOCKTON, CA Telephone (209) 466-6781 ti PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 1 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 made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin i Local Health District. Job Address D r ' City Lot Size PM ,.. Owner's Name Address Phone K� Contractor dress License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT M DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of.Grout Seal_ Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50111ye Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION_�l REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic systern'permitted if public sewer is available within 200 feet.] Installation will serve: Residence-Iff-Commercial_ Other Q Number of living units: Number of be ooms € Character of soil to a depth of 3 feet: 1 Water;able depth SEPTIC TANK ❑ Type/Mfg — Capacity - No. Compartments PKG. TREATMENT PLT. ❑ / 1 J 5 F Method of Disposal 4 f Distance to nearest: Well FTadation PropBrry Line to LEACHING LINE No. & Length of linesy' Total length/size FILTER BED —0 Distance to nearest: Well P� Foundation Property Line �© SEEPAGE PITS ❑ Depth Size Number V, r SUMPS -11 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑\ hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin cdunty 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 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 must call for all required inspections. Comp ate drawing on re rse side. p 1 !1 Signed Title: - -� !�-� gf!: Date: ! FOR DEPARTMENT USE ONLY 11 ' Application Accepted y Date_ �fY� r� Area Pit or Grout Inspecti by Date `G S Final Inspection bye Date i `"Additional Comments: i❑ Stk 466-6781 . ❑ Lodi 36.9-3621 '�'�❑ Manteca 823-7104 . ❑ Tracy •835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,.Stk., CA 95201 r FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH + EH 13-24 IREV.1/a 5) - /1 &—s EH 1426 LA S i