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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 made in compliance with San Joaquin Co Ord"nance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 1 n , /� �� City tat Size PM Job Address jAdPhone Owner's Name � Contractor } Address License No. v Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK `,-SEWER LINES DISPOSAL FLO. 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 ID Domestic/Private D Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public '-F1 Other 171 Delta u Depth of Grout Sea! Type of Grout I — I I I Irrigation _._Approx. Depth l l Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 1 Depth Filter Material (Below 501 51 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I VOfSTRUCTION i I (No septic system permitted if public sewer is 1JJ ,!/r/�/yf� 4 available within 200 feet.) Installation will serve: Residence— Commercial_ Other l Number of living units: Number of b ooms Water table depth Character of soil to a depth of 3 feet: SEPTIC TANK X Type/Mfg Capacity n b No. Compartments y' PKG. TREATMENT PLT. Eltion Method of Disposal `� *` "� "FoilridaLine Distance to,nearest:';", Weli. Property LEACHING LINE ❑ No. & Length of lines _ e Total length/size 617 4' 3 ,..,, FILTER BED ❑ Distance to-nearest.-z--Well#"^'"'""'-"Foundation— Property Line SEEP GE 'ITS t I Depth Size Number 5U P D Distarib"cinedroSt�^� 'Well ^faundation Property Line DISPO L PONDS ❑' _,M I hereby ertify 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 performarice 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, I shall employ persons subject to workman's compensa- tion laws of California." The applicant call for II required coon . Com le drawing on reverse,s}iNd1e. Q-/ 2Title: Date: Signed ,, r � DEPARTMENT USE ONLY f Date Application Accepted by / d Area Pit or Grout Inspection by Date — Final Inspection by Dat ~ 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., GA 95201 3 FEEAMOUNT DUE AMOUNT REMITTEDeCK RECEIVED BY DATE PERMIT NO. INFO +.EH14-2a 3-24(REV.t i n 51 EH 1