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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON CA Fly, Telephone {209} 466-6781 ! i PERMIT EXPIRES 11 YEAR FROM DAT ED {Complete in Triplicate} , i1bed.Application is hereby made to the SanJoaquin Local Health District for a permit to construct and/or install the wt�10 This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump a "W, s Local Health District. ons of the San Joaquin Jab Address T City Lot Size PM Owner's Name Address r hone �� 12 2,Contractor Address S. , I p/ License EYo.[ !;e X_ � J Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC YANK' SEWER LINES DISPOSAL FLD,- PROP. LINE FOUNDATIONAGRICULTURE 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 M 1 Public Specifications�� Other L I Delta Depth.of Grout Seal Type of Grout LLfrrigation __Approz#Det I I Eastern Surface Seal Installed by Repair Work Done ,[a` Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter i Sealing Material (top 501 Depth Filler Material (Below 50'} TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.} Installation will serve: Residence J Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property,Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line I. SEEPAGE PITS I I Depth ( Size Number SUMPS Ll 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 county 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."Contractoes 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 appl' t m st call fquired inspections. Complete drawing on reverse side. Signed 7 itle: Date: CJ • FOR DEPARTMENT USE ONLY Application Accepted by /9 Date /Z Area Pit or Grout Inspection by Date Final Inspection by � (� Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-36211 ❑ Manteca 823-7104 ❑ Tracy 835-6385 . Applicant - Return all copies to: Environmi ntal Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 i FEE AMOUNT DUE AMOUNT REMITTED INFO CASH RECEIVED BY DATE PERMIT'NO. •.EH 13-2 (REV.t i n 51 7� EH 1428 - Cy