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si APPLICATION_FOR PERMIT SAN JOA(2UIN LOCAL'HEALTH DISTRICT 1601 E. HAZEL'+ON AVE., STOCKTON, CA Telephone (209) 466-6781 F PERMIT EXPIRES 1 YEAR FROM DATE'ISSUED 1 {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 Ryles and Regulations of the San Joaquin Local Health District. r. . .. - ' City iLot Size PM Job Address i F i; Owner's Name Address Phone ' Contractor ddress ,. License No. Phone TYPE OF WELL/PUMP; ` NE WELL. ❑,, ,WEL REPLACEMENT ❑ DESTRUCTION ❑ �..: .P0tMP INSTAL-IiAT10N� ° STEM REPAIR ❑ OTHER ❑ �T DISTANCE TO NEAREST: SEPTIC TANK EWER LINES DISPOSAL FLD. PROP. LINE ' FOUNDATION""-� —-AGRICULTURE-WELL7 --OTHER WELL' T _PITS/SUMPS' j INTENDED USE TYPE OF WELL PROBLEM AREA GONSTRUCTION SPECIFICATIONS Y _ _❑ Industrial ❑`Open Bottom- - ❑ Manteca ` ia:of Well Excavation W Dia. of Well Casing ivn Domestic/Private ❑'Gravel Pack E] Tracy Type of Casing Specifications + Type of Grout LJ Public 71Ather El Delta Depth of Grout Seal ❑ Irrigation �pprox. Depth ❑ astern Surface Seal Installed by z f Repair Work'Dohe ❑ Type of Pump H P. t 1""""'��State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 1 Jr Depth Filler Material (Below 50') '' TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRjADDITION ❑ DESTRUCTION ❑ (No septic-system permitted if public sewer is S i F iavaiiable.within 200 feet.) ' l Installation will serve: Residence Commercial_ Other * - Number of living units: 'w Number of bedrooms --` Character of soil to a depth:oQ feet: ' �t`�t � ` d � Water table depth SEPTIC TANK ❑ �l Type/Mfg '" "'�'" Capacity No. Compartments i PKG. TREATMENT PLT. ❑ " Method of Disposal Distance to nearest:_ Well ` F ndation Property Line CC 1 LEACHING LINE ❑ No. & Length of fines Total length'/size I FILTER BEd Elj�i Distance to nearest: Well I 'Foundation Property Line F Yi 1r. �' �- SEEPAGE PITS [III Depth Size Number r SUMPS Ll Distance to nearest: Well -oundat1on -Property-Line DISPOSAL PONDS ❑! t 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 A hich'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." 11 The applicant m call for 4 II re ed 'nspections. Complete drawing on vers ide. -7 ` GAJ Date: f Signed Title: ie FOR DEPARTMENT USE ONLY III L/ � �.` I Application Accepted by, ,a� Date Area, 1 ;§ by Date � Pit or Grout Inspection by I Date Final Inspection Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 iI CK F FEE AMOUNT DUE _ AMOUNT REMITTED CASH RECEIVED BY DATE -PERMIT'NO. YNFO LA �! �s5 +EH 13-24(REV.i/957 --qq3 ' EH 14 } ',�S26 '