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✓ APPLICATION FOR PERMIT ` t 5ANs;,}OAQUIN LOCAL HEALTH DISTRICT �L 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone I209�"1 L�Us PERMIT EXPIRES i YEAR FROM DATE ISSUED r (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.. i1 j 1 V C Lot Size PM Job Address / City Address - ��----TF Phone Owner's Name Contractor �F f Address License No. 01 Phone /�� TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR Cl OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF_WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing L-1 industrial X Open Bottom ❑ Manteca Dia. of Well Excavation Specifications i ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Tp — FI Public I-] Other ❑ Delta Depth of Grout Seal Ya of Grout Type Approx. Depth >(Eastern Surface Seal Installed by I I Irrigation It H P State Work Done Repair Work Done ❑ Type of Pump 1V C.=v�� Well Destruction Well Diameter Sealing Material (top 50'1 Q Depth Filler Material Melow 50') TYPE OF SEPTIC WORK: NEW IN I 1 REPAIR/ADDITION I 1 DESTRUCTION I i avo septic sy t stem 200 feetit,ed if public sewer is Ins_thilation will serve: Residence` Commercial Other f Number of living units: Number of bedrooms v Water table depth Character of soil to a depth of 3 feet I Capacity No. Compartments SEPTIC TANK Cl Type/Mfg PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line C Total length/size LEACHING LINE ❑ No. & Length of lines FILTER BED ❑ Distance to nearest: Well Foundation Property Line I SEEPAGE PITS { I Depth Size Number SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDEl S {I<Ds ' application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and V� I hereby coif){ that l have prepared this app rules and regulations of the San Joaquin Local Health Di?trict. I "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: s to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature employ any person in such manner a 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." I The applicant must cAl for all required ins tions. Complete drawing on reverse side. (� Signed X Title: Date: /S FOR DEPARTMENT USE ONLY i Are Application Accepted by Date__ Pit or Grout Inspection by Date Final Inspection by Date 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. Bax 2009, Stk., CA 95201 I FEECK RECEIVED BY DATE PERMIT NO. AMOUNT DUE AMOUNT REMITTED CASH INFO+.EH 1324(REP.7 EH 14-26