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APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE.T ON AVE.,_STOCKTON, CA f Telephone (209) 466-6781 (PERMIT EXPIRES 1 YEAR.FROM DATE ISSUED ~ 1 (Complete in Triplicate) r Application is hereby made to the San Joaquin Local Health District for a permit 10 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. I Lf City Lot Size PM Job Address r ' h Address Phone Owner's Name /n r Contractor Address T License No.(� Phone v TYPE OF WELL/PUMP: NEW WELL LIWELL REPLACEMENT ❑ DESTRUCTION LJ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD: PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS , El Industrial ` 11 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Il Public fl Other ❑ Delta Depth of Grout Seal Type of Grout k I Irrigation Approx. Depth I i Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done ; Sealing Material (top 50'1 4_.s �WeN Destruction ❑ We11 Diameter 9Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION t. REPAIRIADDITION iJ DESTRUCTION I I (No septic system permitted it public sewavailable within 200 feet.) ee Installation will serve: Residence� Commercial_. Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth Ca acit No. Compartments SEPTIC TANK O Type/Mfg p Y PKG. TREATMENT PLT- ❑ �4 Method of Disposal Distance to nearest: Well Foundation Property Line Total length/size �. LEACHING LINE ❑ No. & Length of lines .y �'� i 'i FILTER BED ❑ Distance to nearest: Well 1.�� Foundation� Property Line ( SEEPAGE PITS 11 Depth cJ� h' Size ' Number .r ( SUMPS L] Distance to nearest: Well 6�40 Foundation 1190 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 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 t �Mq n pections mplete drawing onreverse side.Title: I Date:Sign ;.r FOR DEPARTMENT USE ONLY Date r Area Application Accepted by r // S PR or Grout inspection by Date % Final inspection by Date (/Additional Comments: rs LI Stk 466-6781 ❑ Lodi 369-3621 El Me 823 7104 ❑ Tracy 835 fi385 Applicant- Return all copies to: Environmental Health Permit Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE f INFO MOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. ♦ EH 13-24'(REV.t/n5l S� EH 1428 1'r