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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 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. ii F City� �� Lot Size S PM Job Address Owner's Name Address S�t 'L - Phone Contractor Address ! Z 3 License No.2,65; 26 —Phone 4 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT 09 DESTRUCTION,�j i PUMP INSTALLATION X SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:SEPTIC TANK 00 SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS E� El Industrial, C3Open Bottom [IManteca Dia. of Well Excavation l Dia. of Well Casing Domestic/Private 7 Gravel Pack ❑ Tracy Type of Casing Specifications 71 Public C1 Other Cl Delta Depth of Grout Seal 5-0 Type of Grout - I I Irrigation ".Approx. Depth l I Eastern Surface Seal Installed by U-,Fe - - Repair Work Done ❑ Type of Pump — H.P. — State Work Done I 1 Well Destruction Well Diameter 6 Sealing Material (top 50'1 9} Depth Gj0 Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION t 1 (No septic system permitted if public sewer is available within 200 feet./ Installation will serve: Residence -r Commercial — Other Number of living units: Number of bedrooms Character of soil to a depth of 3'feet: Water table depth b SEPTIC TANK ❑ :..Type/Mfg Capacity No. Compartments k PKG. TREATMENT PLT. ❑ I!ii Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size I FILTER BED ❑ ; Distance to nearest: Well Foundation Property Line ' SEEPAGE PITS I'I Depth Size Number I l SUMPS L1;i Distance to nearest: Well Foundation 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. "I certify that in the performance of the work for which this permit is issued, I shall not Home owner or licensed agent's signature certifies the following: employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature C 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 must call for all required inspections. Complete drawing on reverse side. Signed X Title: 14 �f/Ll Date: F DEP T T USE ONLY Application Accepted by Date Area 1 Date Pit or Grout'Inspection by Dato 4Final Inspection by Additional Comments: I V DIE ❑ 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 FEE AMOUNT DUE AMOUNT REMITTED CKV CASH RECEIVED BY DATE PERMIT NQ. INFO EH 13-24 MCV.IIK51 ' EH 14-28