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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1 RW1 k. 1601 E._HAZELiON AVE.-, STOCKTON, CA Telephone (209) 466-6781 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 C 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. , ds r Job Addra City Lot Size PM Owner's Name �, � � '` ddress pPihon l' Contractor Address �� License No. Phon - TYPE OF WE /PUMP: NEW WELL El WELL REPLACEMENT ❑ DESTRUCTION oovu PUMP INSTALLATION © SYSTEM REPAIR ❑ OTHER ❑ t DISTANCE TO NEAREST: SEPTIC TANK SEWER Ll ES DISPOSAL FLD. PROP. LINE t. , 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other_' r ❑ Delta Depth of Grout Seal i Type of Grout ' i'. ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done El Type of Pump H.P. State Work Done Well Destruction X11 Well Diameter Sealing Material (top 501 Depth Filler Material (Below, } TYPE OF SEP WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will se : Residence_ Commercial_ Oth Number of living uni Number of bedrooms Character of soil to a de h of 3 feet: Water table depth SEPTIC TANK ❑ ype/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal 4 Distan to arest: Well Foundation Property Line.,..' LEACHING LINE ❑ No Length n 'nes Total length/size �'r FILTER BED ❑ istance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Siz 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 k 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 r tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. ! �. Signed X Title: Date: FOR DEPARTMENT USE ONLY 1 Application Accepted by eaiwp Date Area Pit or Grout Inspection byDate vV Final.lnspection,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. Box 2009, Stk., CA 95201 f FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. 1 INFO -y/ CASH + EH13-244REV.,ia5) + G 3 ( -13..S._'4� l •' ��1� 4''(4 Y`'�19 EH 14-28 TT ��J"