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APPLICATION FOR PERMIT 7 SAN JOAQUIN LOCAL HEALTH DISTRICT �' � � ' 1601 E. HAZELTON AVE., STOCKTON, CA � t Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSU Viz? (Complete in Triplicate) NAL- � p,LT1� Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or installf� c� iqc �tfW5his application is " made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and e EBtefations of the San Joaquin Local Health District, r r �j I � Job Address/ City Lot Size PM Owner's Name w ' Address �1 �` r a Phone � �Y] I AddressE , License No/ 7PhonC �6_9 Contractor � TYPE OF WELL/PUMP: NEW WELL F. WELL REPLACEMENT ❑ DESTRUCTION ❑ rl PUMP INSTALLATION'Ll'-- SYSTEM REPAIR ❑ OTHER ❑ I 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing L*Domestic/Private L1Gravel Pack '❑ Tracy. Type of Casing F Specifications - y, M Public (7 Other !:T 11 Delta' Depth of Grout Seal Type of Grout 1 I I Irrigation �.Approx. Dep l I Eastern Surface Seal installed by - Repair Work Done Z Type of Purimp� .< H.P. —� State Work Done Well Destruction ❑ Wei! Diameter Seating Material (top 501 Depth i Filler Material (Below 50') t TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION f I DESTRUCTION I I INo.septic system permitted if public sewer is available within 200 feet.I ' In llation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms Character of soil-to-a-depth-of-3-feet! - s Water table depth. SEPTIC TANK LlType/Mfg Capacity } No. Compartments PKG. TREATMENT PLT. ❑ r `Method of Disposal ' �t h Distance to nearest: t Well Foundation Property Line LEACHING LINE El No. & Length of lines Total length/size I3 FILTER BED ❑ Distance tto,nearest: Well Foundation Property Line SEEPAGE PITS ["I Depth Size Number SUMPS ❑ 'Distance to,nearest: Well Foundation Property Line DISPOSAL PONDS ❑ . h 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 If rules and regulations of the San Joaquin Local Health Dristrict. 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 I 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 ca I for aN req ed inspections. Completedrawingon rev rse side. I Signed X_ gitte: Date: FOR DE RTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date f6 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 f FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE OERMIT NO. d+� INFO EH 13-24(REv.I K S1 � r� EH 14-26 ...._ [� _. �. .