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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE i ON AVE., STOCKTON, CA Telephone (209) 466-6781 ! PERMIT EXPIRES TYEAR 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. City (-0 Q� Lot Size Job Address Address Phone 3 036 Owner's Name ' S Q L License No. A Phone_/ � ISO Contractor L*� Address TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS FIIndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. f Well Casing 171 Domestic/Private El Gravel Pack [I Tracy Type of Casing Specifications 1-1 Public ❑ Other FI Delta Depths of Grout Seal Type of Grout I I Irrigation Approx. Depth i I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H,P. State Work Done Well Destruction ❑- Well Diameter Sealing Material (top 501-- Depth Filler Material (Below 50') t TYPE OF SEPTIC WORK: NEW INSTALLATION EPAIR/ADDITION l I DESTRUCTION t I (No septic system permitted it public sewer is available within 200 feet.) f Installation will serve: Res i ence 'Commercial --Other S Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK _ Q-"Typcee//Mfg Capacity � DO No. Compartments k PKG. TREATMENT PLT. ❑ T` -L- ' //�fQ Method of D{iso aI Distance to nearest: Well Foundation `f Property Line LEACHING LINE R—ITo—& Length of lines r Total length/size FILTER BED El ' Distance to nearest: Well Foundation+ / Property Line SEEPAGE PITS �pth Size S3 Number SUMPS Ll Distance to nearest: Well Foundation Property Line APO 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 agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not G 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 I of Californi . F The applicant t c 11 for I r uire sp Complate drawing on verse si e. Sig Title: Date: FOR DEPARTMENT USE ONLY ; J Application Accepted by Date' Area_ / Z _ _ - it r Grout Inspection by Data . _ Final Inspection by �Date f��--- ' fe Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 El 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 ! FSEAMOUN�TD UEAMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH +.EH 13-24(REV.t/n 51 EH 14-2e