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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 (Complete in Triplicate) 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 Rules and Regulations of the San Joaquin Local Health District. Cit Lot Size PM Job Address Owner's Name Address PhoneVvp Contractor Address License No aS 7 Phone 34` TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I 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 l ❑ Domestic/Private. ❑ Gravel Pack ❑ Tracy Type of Casing Specificationk FI Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation --Approx. Depth I 1 Eastern Surface Seal Installed by 4 _ Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material {top 50'1 j Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION PPIESTRUCTION I 1 INo septic system permitted if public sewer is Iavailable within 200 feet.) Installation will serve: Residence�Commerciaf— ther Number of living units: NumberMoms Character of soil to a depth of 3 feet: Loa JTN, Water table depth SEPTIC TANK I ❑ Type/Mfg Capacity No. Compartments I t PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line f r !CEAGHING/LINE ? 0 No. & Length of lines '+ Total length/size i FILTER B.EDD ❑ 'Distance to nearest: Well Foundation p Property Line .f P SEEPAGE PITS (41-1bepthV:'2 TI Size Number { � SUMPS Ll Distance to1 i nearest: Well�� Foundation 6_10 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�co n[y'ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. fi tt Home owner or licensed agent's signature certifies the,�follorin;g:,"I certify that in the peor�mance of the work Sfor which thls permit is issued I shall n employ any personpri such manner as to become subjectrto wrirk tlan's compensation laws of-California."Contractors hiring ng oy sub-contractin signat certifies the following: "I certify that in the performance of the yMrk.fpj whicbLthis permit is issued, I shall employ persons subject to workman's Compensa tion laws of California." ! ' t 1 y The applica -m r cal or all requi in ctions. Complete drawingtion reverse side. f f Signed X f Title:��>�� r } � Date: i � �T FOR DflPARTMtNT.USE ONLY T Application Accep od by * `'r 'Date Area ZCZ 7 f Pi or Grout Inspection by Dat _ ina'In pection by ate Additional Comments: �. - ' r + ❑ Stk 466-6781 "C]Lodi"369=3621,,1 L"8 Manteca)-823-7104 0-Tracy t 835-6385 Applicant - Return.all copies to: Environmental•Health,.Perrnit/SerVices 1601'E, Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1FEE !�/ _ jr � � INFO AMOUNT DUE AMOUNT REMITTED OK H; RECEIVED BY DATE, PERMIT'NO. � 191 r 1�1 ♦.EH 13-24(REV.1 i x s; d ' EH 14-2e �