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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED. (Complete in Triplicate) Application is hereby[Wade to the San Joaquin Local Health District for a permit to construct andlor install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 tar sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. f Job Address Cit Lot Size/ J PM Owner's Nam •Address Phon y Contrac f dress icense No„ p z�`�` Phone S TYPE OF WELL/,PUMP: NEW WELL ❑ WELL REPLAC_ ENT ❑. DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC:TANK �' SEWER--LINES DISPOSAL FLD. PROP. LINE b FOUNDATION AGRICULTURE WELD OTHER WELL PITS/SUMPS INTENDED USE _ TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS. ❑ Industrial 1 ❑ Open Bottom -❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ' 'HCl Gravel Pack ❑ Tracy Type of Casing Specifications Fl Public ❑ Otheri... ❑ Delta Depth of Grout Seal Type of Grout I 1 Irrigation __Approx. .Depth i I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump W.P. State Work Done _ r Well Destruction ❑ Well Diameter' Sealing Material (top 501 O Depth - "' "` Filler Material (Below 50'I TYPE OF SEPTIC WORK: NEW INSTALLATION I 'REPAIR/ADDITION (-I DESTRUCTION l I INo.septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence! Commercial^°'/Othe r Number of living units: _�_ Number of he ooms � -� Character of soil to a depth of 3 fact: Water table depth SEPTIC TANK ❑ Type/Mfg f (Capacity No. Compartments PKG. TREATMENT PLT. ❑ y Method of Disposal Distance to nearest: - Well Foundation Property Line f 'r 40i 4 LEACHING LINENo. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Weil F-oundation Property Line�~ � Number SEEPAGE PITS i I Depth Size �r SUMPS Distance to nearest: Well!n' Foundation_.,Property-Line ` DISPOSAL PONOS ❑Y..� T 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 Di%ttict. 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 which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant call for a re uir inspections. Complete drawing on reverse sid Signed Title: Date: FOR DEPARTMENT USE ONLY z kApplication Accepted by Date T Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 FEEAMDUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'N0. INFO �j k +:EH13-2�[HEV.r/H5Y 7 0—�^37� CHI L�