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APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1. 1601 E. HAZEL i ON AVE.,B STOCKTON, CA Telephone (209) 6781 PERMIT EXPIRES 1 YEAR'FROM DATE ISSUED IFS, l {Complete in Triplicate} t 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 Ryles and Regulations of the San Joaquin Local Health District. �I t Job Address Ci Ldt Size PM Owner's Name �w#. - Address _ Phone' 'l fContractor �'i n, Address �/'� - • *�; ` � L-icense No."�Z�� TYPE OF WELLlPUMP: _ �• �-- _Phone - i ;j' EW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ry PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LiNEOTHER ❑ LINES FLD. PROP. LINE FOUNDATION .� FOUAGRICULTURE WELL OTHER WELL t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS- E-] PITS/SUMPS Industrial ID Open Bottom El Manteca Dia. of Well Excavation ED Domestic/Private L3 Gravel Pack Dia. of Well Casing ❑ Tracy Type of Casin ❑ Public ' g Specifications EJOther El Delta ---Depth-of'Grout Seal ❑ irrigation _� Depth pprox. EJ Eastern - -TYPe of Grout Surface Seal Installed by �. Repair Work Done ❑ Type�1of Pump H.p E Well Destruction ❑ Well DiameterState Work Done Sealing Material (top 50') ' Depth Filler Material(Below 501) TYPE OF SEPTIC WORK: NEW INST TION.0-]'' EPAfR DDITION= DESTRUCTION ❑ fNo septic system permitted if public sewer is Installation will serve: Residence available within 200 feet.) Commercial_ Other ; Number of living units:/' Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK 11 Type/Mfg T =Water table depth PKG. TREATMENT PLT..❑ i Capacity No. Compartments �S c ° Method of Disposal Distance to nearest: Well Foundation` Property Line LEACHING LINE 2'-�No & Length of linesG `- Total lerigth/size— FILTER BED ❑ Distance to nearest: Well Foundation 1,. !O i ~ l� Property Line - SEEPAGE PITS Depth Size SUMPS �� Number ❑ Distance to nearest: Well 1,Or� Foundation irJ/ '� DISPOSAL PONDS ❑ I� ��-� Property Line fl% � I hereby certify that I have prepared this application and that the work will be done in deco dance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. ;a _ 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: 'T 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." f The applicant mustcall for all requir inspections. Complete drawing on reverse side. Signed a _ r 9 Title: Date: 11 FOR DEPARTM T USE ONLY Application Accepted by 11 Date Area " ?/ Pit or Grout Inspection by Date ,r ��° �►-,� / Final Inspection,by .Additional Comments: + ' ❑ Stk 466-6781 ❑ Lodi 369-3621 LlMantecaManteca 823-7104 ❑ Tracy 835-6 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave. -P.O. Box 2009, k., CA 11 FEE /NFO AMOUNT DUE AMOUNT REMITTED CK RECEI ED BY f CASH DATE. PERMIT N0. +EH13.24(REV.>/as) _ ¢ �00 _ � .'/�� EH 1426 _ �. � 3� y, i .