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I APPLICATION FOR PERMIT B S , SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA woLo �c�ry�-'`' l Telephone {209) 466-6781 C�n,f NI PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 17 `1D (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 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. I S L r I)9�! 7' City Lot Size PM Job Address n _ Owner's Name dress ✓ J Phone Contractor Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLA MENTF❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ - SYSTOIREPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SE R LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRIC TUR WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA NSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. Well Excavation Dia. of Well Casing Y ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of ing - Specifications l'1 Public f I Other {❑ Delta Depth of Gro Seal Type of Grout — I 1 Irrigation —.Approx. Surface Seal Insta d by Depth I I Easter State Work Done Repair Work Done [3 Type of Pump H.P. _ 1 i Well Destruction ❑ Weil Diameter Sealing Material Itop 50'1 1 Depth Filler Material Ill 50'1 -- TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I I DESTRUCTION (No septic system permitted if public sewer is I available within 200 feet.) � Installation will serve: Residence�� Commercial_ Other Number of living units: Number of bedrooms Character of'soil to a depth of 3 feet: Water table depth l SEPTIC TANK ❑ { Type/Mfg,) Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal I i Distance to nearest: Well Foundation Property tine . LEACHING LINE LINo. & Length of lines Total length/size FILTER SED ❑ Distance to nearest: Well Foundation Property Line i SEEPAGE PITS i I Depth I Size Number SUMPS ❑ 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. 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: "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 in coons. Complete drawing on reverse side. Signed X -Title: Date: 't� 4 t- O PAR ENUSE ONLY Application Accepted by 'r"� Date Q+ Area G, Pit or Grout Inspection by Data Final Inspection by Date '' Z J 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 955201 r , FEE AMOUNT DUE i AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. I INF Q +.EH13.241REV.rlH51 1 14-28