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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 t 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. r Job Address S City of Size PM ( �Q+ _ Address UPhone Owner's Name-" " lAddress License No. Phone Contractor TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT FIDESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHE 171 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 r Specifications ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing S P f 1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout i I I Irrigation —.-Approx. Depth t I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Stop 501 Depth 7 Filler Material (Below 501 TYPE OF SEPTIC WORK: NE INSTALLATION I:i REPAIR/ADDITION I I DESTRUCTION I I (Noavasblpelwthine200 feeft}ed if public sewer is t.Installation will serve: Residence Commercial_ Other Number of living units: Numb of bedrooms Character of soil to a depth of 3 feet: Water t epth SEPTIC TANK ❑" Type/Mfg Capacity . Compartments PKG. TREATMENT PLT. ❑' Method of Disposal Distance to nearest: Well Foundation Property Line I i LEACHING LINE ❑ No. & Length of lines Total length/size r FILTER BED iO Distance to nearest: Well Fo ation Property Line I SEEPAGE PITS 1 ! DepthSize Number SUMPS Ll Distance to earest: Well Foundation Property Line f 1 y , 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. ertify 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: "I c 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 call f r all required in ti ns. Comp to drawing an reverse side. �} f '7 Signed Xy� � f Title: Date: I FOR DEPARTMENT USE ONLY 1 Q Application Accepted by Date r-� Area—/� Pit or Grout Inspection by ate Final Inspection by Additional Comments: y ❑ 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, 5tk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTEDASR RECEIVED BY DATE PERMIT NO. INFO r + EH 13-241REY.r/ws) 1 sem! '"[ C/_/y� � EH 14.26 v s, f