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;i ` A. ' APPLICATION FOR PERMIT =- SAN JOAQUIN LOCAL HEALTH DISTRICT �7 1601 E. HAZEL i ON AVE., STOCKTON, CA J ` Telephone (209) 466-6781 Q PERMIT EXPIRES TYEAR 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 weir/pump and the Rules and Regulations of the San Joaquin Local Health District. j�, [� rci e H City d�< v Size PM CJobAddresspJtiL fU Address 5�C r. 4aJ� Phone �� -�er's Name tractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACE ENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM 'AllR ❑ OTHER ❑ r DISTANCE TO NEAREST: SEPTIC TANK /' :— EWER LINES `` DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA C,ONST.RUCTION SPECIFICATIONS ElIndustrial ❑ Open Bottom ❑ Manteca /bia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy el Type of Casing Specifications' f D Public ❑ Other ❑ Delta V Depth of Grout Seal Type of Grout _ l I I ifrigation ,Approx. Depth I ) Eastern Surface Seal Installed by I Repair Work Done ❑ Type of Pump I H.P. State,Work Done_ Well Destruction ❑ Well Diameter Sealing Material ifop 501 „ t Depth — Filler Material Welow 50'1 I TYPE OF SEPTIC WORK: NEW INSTALLATION I'l REPAIR IADDITION I I DESTRUCTIO,i1L'1 "(No septic system permitted if public sewer is \available within 200 feet.) Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth l „ SEPTIC TANK ❑ " Type/Mfg Capacity No. Compartments VI} r PK.G. TREATMENT PLT. ❑ „ "' _, _ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. R Length of lines Total length/size FILTER BED LJDistance to nearest: Well Foundation Property Line SEEPAGE PITS I'1 Depth Size Number SUMPS D Distance to nearest: Well Foundation 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 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." 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, l shall employ persons subject to workman's compensa- tion laws of California." The applicaill must call II for .required inspections. Complete drawing on reverse side. #�� Signed X � Title: Date: r VI FOR DEPARTMENT USE ONLY Application Accepted by Date � — D rea / Pit or Grout Inspection by Date�_._. Final Inspectiony/ Date Additional Comments: / r ❑ Stk 466-6781 ❑ Lodi 369-3621 Manteca 823-7104 LJ Tracy 835-6385 Applicant -.Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2008, Silk., CA 95201 r FEE AMOUNT DUE AMOUNT REMITTED CK III RECEIVED BY DATE PERMI7�NO. ~ INFO k +-EH 13-24(REV.tix5) �S �V/ r -- EH 14-25 ...7 _J