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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA 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 I 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. Job Address — WCA- W -C- kity Lot Size PM Owner's Nameress Phone (5'-_7 0 n Contractor 1 f ddress License No.3�6�7-Phone t TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 1-r�- r PUMP INSTALLATION SYSTEM REPAIR 11OTHER ❑ 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 r ElIndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing :,:Public Domestic/Private LJGravel Pack El Tracy Type of Casing Specifications r 1 n Other 7 Delta Depth of Grout Seal Type of Grout t _N1I I Irrigation Approx. Depth- I I Eastern ' Surface Seal Installed by Repair Work Done EJ Type of Pump if'••' H.P. s State Work Done C Well Destruction ❑ Well Diameter Sealing Material atop 501 Depth Filler Material IBelow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence-t- Commerci Other _ Number of living units: Number of be oms Character of sail to a depth of 3 feet: Water table depth SEPTIC TANK' ❑ Type/Mf Capacity No. Compartments PKG. TREATMENT PLT. ❑ 1 Method of Disposal istance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line S AGE PITS I 1 Depth Size Number F K SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS r-. ❑ 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 1 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." s The applicant must call for all req {red ' specti ns. Complete drawing on reverse side. Signed X Title: Date: ~7�•" FOR DEPARTMENT USE ONLY Application Accepted byH Date Area U Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Stk 466-6781 ❑ Lodi 369-3621 0 Manteca 823-7104 ❑ Tracy 835-6385 pplicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH /� ]7 Y a EH 13-24{REV.5/H 51 --j-) 3 r j - /� if 7—,r / EH 14-26