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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA f 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 well/pump and the Rules and Regulations of the San Joaquin' Local Health District. E x ' Job Addressg� City t Size PM Owner's Name q _,,.,Address Phone r i Contractor _`�+�-�' Address ense No.�� Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 171 PUMP INSTALLATION SYSTEM RtPAIR ❑ OTHER LJ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - ` DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBL4.4REA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca ,, Dia" of Well Excavation Dia. of Well Casing A A { ! V ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other i 177 Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth❑ Eastern ',Surface Seal Installed by Repair Work Done Ll *Type of Pum H.P. State Work Dane Well Destruction ❑ i Well Diameter Sealing Material (top 501 ' Depth —. Filler Material (Below 501 = 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 I Number of living units: Number of bedrooms } Character of soil tfi-a dept}i-6f-3-faet. Water table depth •s`� SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments 1 PKG. TREATMENT PLT. ❑ " Method of Disposal 4 r Distance to nearest: Well Foundation Property Line : k � LEACHING LINE ❑ No. & Length o•lines Total length/size d FILTER BED ❑ Distance to nearest: Well Foundation Property Line R SEEPAGE PITS ❑ Depth - Size Number b � SUMPS r ❑ Distance to-nearest: Well Foundation Property Line # DISPOSAL PONDS ❑ I hereby certify that I have prepared thA Application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an ia 4 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 shat!not k employ any pe -in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signaturke r certifies th ollowing:"I certify that in the performance of the work for which this permit is issued, I 'shall employ persons subject to workman's compensa t '):ion a(awws of California." The applicant/U call for all required inspections. Complete drawing on reverse side. 6 1 r'/ Ljv� � 'f• Date: I /Xv Signed r7 FOR DEPARTMENT5ENY AQplicatinn Accepted by r� DateAreaPit or Grout Inspection by Date on by Date %�`�J Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy' Applicant -.Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT r RE�I.TTEMD fCASFE kFfE�I�EIVED BY\i�1 � 4ATy�E/—am/ '.PERMIT NO. INFO ♦ Ek 3-241REV. es) o ' k EH 1448 +