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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 486-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit 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. c Job Address Cit Lot Siz � PM t Owner's Name gwn Address z Phone r j a ContracteW Address �. License No 2 •Z Z-4 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR D OTHER ❑ 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 r 1 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 1 ❑ Domestic/Private © Gravel Pack ❑ Tracy Type of Casing Specifications 1 f7 Public 17 Other f--1 Delta Depth of Grout Seal Type of Grout I i Irrigation —.-Approx. Depth 1 Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material atop 501 Depth r Material (Bel w 501 — TYPE OF SEPTIC WORK: NEW INSTALLATION 11 EPAIRIADDITION DESTRUCTION l I Wo septic system permitted if public sewer is 4y ti 8// available within 200 feet.) /p Installation will serve: Residence_ Commercials f Other Number of living units: L Number of d ooms Character of soil to a depth of 3 feet: A Water table depth SEPTIC TANK 1 ❑ Type/Mfg ` Capacity � Y No. Compartments ^ PKG. TREATMENT.PL-T. 0_- Method of Disposal r Distance to nearest: Well Foundation Property Line a _ LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line N SEEPAGE PITS Depth Size " r Number SUMPS Ll Distance to nearest: Well 7,- - Foundation��/ Property Line r w - _f`n 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 Dstrict. • / 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,l shall employ persons subject to workman's compensa- tion laws of California." The applicant t call fo eq ed inspections. Complete drawing on reveg—lP Signed Title: Date: FOR R DEPARTMENT USE ONLY Application Accepted by -Date — Area oPior Grout Inspection by� ata�_ z Final Inspection byt DateV Additional Comments: _ r II ❑ SIR 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 ❑ 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 CK 0 CASH RECEIVED BY DATE PERMIT'NO. INFO +.EH 13-24IREV. EH 14-M l f