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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL 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 I 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. Job Address City CgSerbAL of Size PM Owner's Name * Address r Phone V —T— wr I -17 6n Contractor - Address License No. A Phone TYPE OF WELL/PUMP: } NEW WELL ❑ WELL'REPLACEMENT ❑ DESTRUCTION ❑ APUMP INSTALLATION ❑ SYSTEM REPAIR .❑ OTHER ❑ DISTANCE TO NEAREST. SEPTIC TANK SEWER LINES,,: DISPOSAL FLD PROP. LINE E�:7 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE, T TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 11 Industrial -- E� Open Bottom ❑ Manteca ✓ Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy,/V Type of Casing Specifications Ll Public _ ❑ Other _ t ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ti ❑ Type of Pump H.P. State Work Done r Well Destruction ❑ Well Diameter Sealing Material (top 50'1 1! Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALL=ATION ❑ REPAIR/ADDITION LiDESTRUCTION No septic system permitted if public sewer is ^ ,r 1 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: i Water table depth SEPTIC TANK i 171 Type/Mfg z Capacity No. Compartments PKG. TREATMENT PLT. ❑ I Method of Disposal --Distance'to nearest: - Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ 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, 1 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 ust all for all required inspections. Complete drawing on r verse side. ! Signed Title: — Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area Grout Ins action b Date Final Inspection by r' nDate PitorGo _. p Y Additional Comments: MAI( ❑ Stk 466-6781^— - ❑ Lodi 369-3621 Manteca 823-7104r ❑ Tra 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO +EH 1324 4REV.I/e 5) S_. EH 14-28