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APPLICATION FOR PERMIT F SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICornplete in Triplicate) 10 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 i Local Health District. r `J\N 'L ob)Address e City Lot Size PM 1 �j Owner's Nam Address Phone 1 j Contractor ;J 1 Address AoyLicense No. Phone L 31. TYPE OF-WELL/PUMP:; NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 171SYSTEM REPAIR C7� OTHER Ll DISTANCE TO NEAREST:-SEPTIC TANK SEWER LINES r ,DISPOSAL-FLD.�' ��` PR6P."LINE.4 FOUNDATION AGRICULTURE.WELL OTHER WELL-------:-,- PITS/SUMPS �...1 !NTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bo`tom`` t ❑ Manteca -y'Dia-'of Well Excavation Dia. of Well Casing ! ❑ DBmestic/Private Cl Gravel Pack' II ❑ Tracy \5 -Type of Casing f Specifications Q r-I Public s t I-1 Other" � i Cl Delta, � Depth of.Grout Seal f Type of Grout = C I I Irrigation _-Approx. Depth ' t I Eastern Surface Seal Installed by s j f Repair Work Done 13 Type.6f Pump I H.P. State Work Done Well Destruction ❑ Well Diameter 1 Sealing Material Itop 501 i `r • 1 a I Depth; Filler Material (Below 50'? -- TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION iDESTRUCTION I I (No septic system'permitied if public sewer is r available within 200 feet.I Installation will serve: Residence.'`w Commercial Other r +. Number of living units: N[nbe"t of bedrooms r `t ` Y� Character of soil to a depth of 3 feet: r e �' -t-+ Water table depth SEPTIC TANK ❑ Type/Mfg ! Capacity No. Compartments PKG. TREATMENT PLT. ❑ , t, Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE' L7 No. &.Length of lines F I (Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth _: y- Size Number e, t SUMPS, L 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 agerit's signature certifies the following: "I certify that in the performance of the work for which;this permit is issued, I shall not k employ any person in such mariner 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." I .j:.,..._- r _ r f The applicant must call for all required ns. Co late drawing on reverse side. r I'.a t 1 d, 'C Signed X I Title: � -1h _ Date: ! e f E —DEPARTMENT,USE ONLY G t Application Accepted byt "b -Date 34 1-'- :_Q Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 935-6365 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 a FEEOUNT DUE AMOUNT REMITTED CCASH RECEIVED BY DATE PERMIT'NO, INFO F +.EH 13-24 E 14-28(REV,1/H 5) H l!