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APPLICATION FOR PERMIT r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA r. Telephone (209) 466-6781 , PERMIT EXPIRES ]'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 welUpump and the Rules and Regulations of the San Joaquin Local Health District. k' Job Address zip City Lot Size PM ` Owner's Name , dr Phone Contractor44 Address License No. Phone TYPE OF WELL UMP: NEW WELL El WELL REPLACEMENT DESTRUCTION El PUMP INSTALLATION ❑ _ SYSTEM REPAIR ❑ 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 C1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia: of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy.- Type of Casing Specifications F1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation —.Approx. Depth I 1 Eastern Surface Seal Installed by _ Repair Work Dane ❑ Type of Pump H,P, State Work Done _ Well Destruction ❑ Well Diameter aling Material (top 501 Depth A Filler Material IBelow 501 } TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION f I "DESTRUCTION I I INo septic system permitted if public sewer is r available within 200 feet.] Q J.. Installation will serve: Residence Commercial_ Other t C Number of living units. J Number of bedrooms Character of soil to a depth of 3 feet: Water table depth -SEPTIC TANK ❑ Type/Mfg Capacit Q� No. Compartments l PKG. TREATMENT PLT. ❑ ^ Method of Di sal Distance to nearest: Well 4� 0 Foundation Property.Line LEACHING LINE ❑ No. & Length of lines ''� Total length/size FILTER BED ❑ Distance 10 nearest: Well�s�[ Foundations Property Line EEPAGE PITS 1 I Depth Size Number _ } t SUMPS Ll Distance to nearest: Well Foundation Property Line i DISPOSAL PONDS ❑ t 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 applicas I requir d spections. Complete drawing o rev rs side. Signed X 71P Title: Date: i FOR DEPARTMENT USE ONLY Application Accepted by C Date .3 A 0 Ar Area ' Pit or Grout Inspection by Date Final Inspection by Date i Additional Comments: _ } ' I ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Perm-it/ 18131 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO �J CASH ,.-3,H 13-24 REV. 51 H14-28 F—;,241 — `2( y 91 �W I