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i I APPLICATION FOR PERMIT 0� ppd SAN JOAQUIN LOCAL HEALTH DISTRICT 6 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone 12091- PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I (Complete in Triplicate) I 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 of the San Joaquin Local Health District. I� 7 Job Address /' r " City of Size PM Owner's Name !I Address r h ne d -� Contractor Address 41Cnse No. Phone TYPE OF WELL/PUMP: I� NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION5W PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE 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 1-1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1-1 Public ❑ Other F1 Delta 'Depth of Grout Seal Type of Grout I iIrrigation --Approx. Depth I 1 Eastern Surface Seal Installed by _ Repair Work Done ❑ Typeihof Pump H.P, State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 50') R Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION I I DESTRUCTIO (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence_.._ Commercial_ Other Number of living units: �M Number of bedrooms I Character of soil to a depth of 3 feet: Water table depth `SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, C1 IN 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 I I Depth Size Number SUMPS C-I 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 Di§trict. i 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 i 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.' j The applicant must call for all re�quirad inspections. Complete drawing an reverse side. ,I p � Signed X Title: to Date: D 5 2S I� FOR DEPARTMENT USE ONLY Application Accepted by Data Area p Pit or Grout inspection by I� Date Final Inspection by Data a Additional Comments:?jj I` ❑ Stk 466-6781 ❑ Lodi,I1 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 95.201 I� I FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. ; INFO it { +.EH13-241REV,1i851 EH 14 26 ✓ D I`h ,