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APPLICATION FOR PERMIT Fill SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED 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 ofJthe an Joa n LocaA H District. Job Address ! t '� •au 6 Owner's Name f Address Phone j— Contractor's Name License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT [] DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE - FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �E INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r x i ❑ Industrial ❑Open Bottom ❑ Manteca Dia, of Well Excavation Domestic/private ❑Gravel Pack ❑Tracy Dia. of Well Casing ❑ Public ❑Other ❑ Delta Type of Casing F-1irrigationApprox. F]Eastern ❑Cathodic Protection Depth Specifications Depth of Grout Seal ""+ ❑Geophysical Type of Grout �- ❑Other E Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction❑ Well Diameter Sealing Material (top 50') _ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑I (No septic tank or seepage pit permitted if public sewer.is Q # available within 200 feet.) r�! Installation will serve: Residence Commercial Other QY i — Number of living units: Number of bedrooms. Lot size f Character of soil to a depth of 3 feet: Water table depth ;SEPTIC TANK ❑ Type/Mfg �} ' �.. Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal ;SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION _ LEACHING LINE EJ No. & Length of lines Total length/size / - FILTER BED . Distance to nearest: Well Foundation Property Line /G SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line r DISPOSAL PONDS ❑ I hereby"certify that I have prepared.-this application and that the work will be done in accordance with San Joaquin county w 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 s 11 not employ any person in such manner as to become subject to workmank compensation laws of California." Contractor's hirin r sub-contractin signature certifies the following: "I certify that in the performance of the work for which �} this-permit is ued, I shall,:.em persons subject to workman's compensation laws of California. ' The applicant t call r-a]; a ctions. Complete drawing = reverse side. Signed X Title: ... Date: ! OR OE • TMENT USE ONLY. t k Application Accepted by °Z' . Area ❑ Stk 466-678 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by Date [� Manteca 823-7104 1 Final Inspection by Date.�� ❑ Tracy 635-5385 L Applicant - Return all copies to: Environmen 'Wealth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 as FEE BASE r AMOUNT DUE AMOUNT REMITTED_ RECEIVED BY DATE PERMIT NO. 1 { INFO