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APPLICATION FOR PERMIT SAN JO_AO.UIN LOCAL HEALTW DISTRICT 1601 E. HAZE�TON AVE., STOCKTON, CA Telephone 1209} 466-b781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED {t�kJ'"' (Complete in Triplicate) , Application is hereby made to the San Joaquin Local Health District far 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 welllpump and the Rules and Regulations of the San Joaquin Local Health District. , Jab Address G i i Owner's Name Contractor's Name TYPE OF WELL/PUMP: NEW WELL ❑ PUMP'1NSTALLATION ❑ DISTANCE TO NEAREST: SEPTIC TANK FOUNDATION INTENDED USE ❑ Industrlel ❑ Domestic/Private ❑ Public ❑ Irrigation Repair Work Done ❑ Well Destruction ❑ i� ,� j ,� � ' , License No. WELL REPLACEMENT ❑ DESTRUCTION ❑ SYSTEM REPAIR ❑ OTHER ❑ SEWER LINES DISPOSAL FLD. PROP. LINE AGRICULTURE WELL OTHER WELL PITS/SUMPS Za. Phone TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Open. Bottom ❑Manteca Dia. of Well Excavation ❑ Gravel Pack ,� ❑Tracy Type of Casing ❑ Other " .,I��-V❑.Delta�� Depth of Grout Seal _�4pprox. Depth ❑ Eastem'��'� Surface Seal Installed by Type of Pump •''� H.i':-`�---.-.. State�lyork Done Well Diameter Sealing Material flop 50'1 Depth � Filler Material [gel 50`1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ lNo septic system permitted if public sewer is available within 200 feet./ Installation will serve: Residence! Commercial �`�40ther / �"� Number of living units: � Number of bedrooms �._ __ f Character of soil to a depth of 3 feet: �– Water table depth SEPTIC TANK ❑ Type/Mfg Capacity � — No. Compartments PKG. TREATMENT PLT, ❑ Method of Disposal Distance to nearest: Well Foundation � � Property Line k LEACHING LINE No. &Length of lines � � '�� I Total length/size_ � /-r'' FILTER BED ❑ Distance to nearest: Well - ALO L� Foundation �� Property Lina s�_ Dia. of Weli Casing Specifications Type of Grout_, � SEEPAGE PITS I SUMPS DISPOSAL PONDS �pepth � �• � � -Size �� Number � ❑ Distance to nearest: Well � GG Foundation. , �a� Property Line � n r I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state lawsr and rules and regulations of the San Joaquin Laca1 Health District. Home owner or licensed agent's signature certifies the folbwing: "I certify that in the perfom7ance of the work for which this permit is issued, k shall not employ any parson in such manner as to become subject to workmen's compensation laws of California." Contractors hiring or sub -contracting signature certifies the following: "1 certify that in the performance of the w_ ork for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant mus tail for all required insp�elctions. Complete drawing on reverse side. � �, ...,_, _ ,,,,,,,,,,,�,i Signed � � ,"'Q'"' � ~ Title: r �--- _.._ � � Date: /p — �� —8 y� �- . � PARTNIlENT USE ONLY Date � �/��8`l �L Application Accepted�by Area /D /�'� Pit or Grout Inspection by . � to 0 g Final Inspection by Date Additional Comments: ❑ Stk 4t>Cr6781 ❑Lodi 369-3621 ❑Manteca 823-7104 ❑Tracy 836-8385 Applicant -Return all copies to: Environmental Health PermRlServides 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT"N0. INFO + EH 13.7A (REV. EH 1414 p o ��