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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE TON AVE., STOCKTON, CA -Telephone (209) 466-6781 PERMIT EXPIRES 1.'YEAR FROM DATE ISSUED f (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 Rules and Regulations of the San Joaquin Local Health.Distric 0 PM K Job Address ' f r City Lot Size % Owner's Name Address :` Phone ContractorAddressLicense No. 3 Phone . ` -TYPE'OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ {/ 7- 1PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ . DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE j FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ,ry INTENDED USE TYPE OF WELL- - PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 0 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications } LlPubic ElOther ClDelta Depth of Grout Seal Type of Grout ,k '❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by t Repair Work Dane ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 f 'TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is [� available within 200 feet) �] Installation will serve: Residence Commercial Other *, Number of living units: __.r[__ Number of bedrooms Character of soil to a depth of 3 feet: "" I Water table depth SEPTIC TANK ❑ Type/Mfg ^ Capacity No. Compartments PKG. TREATMENT PLT. ❑ r Method of Di osal f Distance to nearest: . Well Foundation' s Property.Line .__ LEACHING LINE DkNo. & Length of lines Total lengtt h/size FILTER BED ❑ Distance to nearest: :Well Foundation Property,6ne SEEPAGE PITS \❑ Depth Xf ize �Number v UM Distanc to nearest: Well [ . Foundation Property Line ._ DISPOSAL PONDS ❑\.,,' herey..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. , rte. 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 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 whichtills permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." The applicant must c for all re fired nspections. Comp/ drawing on r se side. I !-! o Signed Title: •/� � Date: FOR DEPARTMENT USE ONLY r Ap ✓� Date —F,7 Area L 2— _ tion Accceepted b P+t�nr,Groui�lrfspection by f U Date Final Inspection by Date. -r .^ 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 t FEE AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT'NO. � INFO � /I 1� ��^^y77 �7 �y + EH 13.24{REV.s a 5) V OU 1 '/ EH 1426 1 J C/ a �