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APPLICATION FOR PERMIT �� f ''- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 County Ordinance No.549 for sewage or No. 1862 for wevIoump and the Rules and Regulations of the San Joaquin , Local Health District. + - L City �C'fL i t►� Lot Size PM Job Address e /� (� S Gv it Address '-t'� 1�1LZ� Phone '-+ T 2- S Owner's Nam Contractors. Address License No. 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 PRO13LEM AREA CONSTRUCTION SPECIFICATIONS i ❑ Industrial w❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 1 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1`1 Public f-10 ther ❑ Delta Depth of Grout Seal Type of Grout a I Irrigation _.Approx. Depth I ! Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter. Sealing Material (top 50') Depth Filler Material (Below 501 ( p TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION t 1 DESTRUCTION l Iftf vailabpelwithine200 feet�tted it public sewer is V� Installation will serve: Residence— Commercial_ Other Number of living units: Num her of bedrooms Character of soil to a depth of 3"feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ [ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines _ Total length/size 'h FILTER BED ❑ Distance to nearest: Well Foundation Property Line I I i SEEPAGE PITS I I Depth Size Number SUMPS/ ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and I hereby certify that 1 rules and egulations of the San.Joaquin Local Health district. Home ovvner 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 I 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 must call for all required inspections. Complete drawing on reverse side. Signed X' Title: Oc � —2 — Date: FOR DEPARTMENT USE ONLY Application Accepted by Area Pit or Grout Inspection by Date Final Inspection by Date Q dX 7 Additional Comments: / / � � y �� `� ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835- 85f— Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 J" /J FEE AMOUNT DUE AMOUNT REMITTED OK RECEIVED 13Y DATE PERMIT NO. L5rr2a�1 ♦ EH 13-241REV.1/k51INFO EH 14-26 1 . E��