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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) s f 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 F 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. IJ VN4 City t Lot Size / �r PM Job Address d ' r! ` - Phone } Owner's Name Address Tc= License No. �672-f Phone ^j Contractor's Name TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTflUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 0(1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private E3Gravel Pack 11Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout (� ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done i Well Destruction ❑ Well Diameter Sealing Material Stop 50'1 Depth Filler Material (Below 50' TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) __ rc . � . Installation will serve: Residence commeial Other Number of living units: f Number of beorooms — Character of soil to a depth of 3 feet: Water table depth ) SEPTIC TANK f3�Type/Mfg"'-_'1 Capacity No. Compartments r PKG. TREATMENT PLT. ❑ _ _ + Method of Dipopi f o Distance to nearest: Well �� Foundation '{� Property Line LEACHING LINE T No.-&Length of lines U j Total length/size r f FILTER BED C]- Distance to nearest: Well� Foundation Property Line SEEPAGE PITS �Depth Size_ :+f. Number SUMPS ❑ Distance to nearast: Well 11 Foundation Property DISPOSAL e — 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. r 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 n employ any person in such manner n to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies'the following: 111 certify that in the performance of the work for which this permit is issued,t shall employ persons subject to workman's compensa tion laws of California." The applicant must call or all equired inspections. Complete drawing on reverse side. /� Signed Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by r Date � r Area ' - Date �� Final Inspection by Date` "_ _Z_ Pit or Grout Inspection by - Additional Comments: ` 'f. ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy $356385 F Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 GK# RECEIVED BY DATE PERMIT NO. FEE AMOUNT DUE AMOUNT REMITTED CASH INFO +EH 13-211REV.101831 EH 1426 - -- --