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APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA l Telephone (209) 466-6781 PERMIT EXPIRES 1"YEAR FROM DATE ISSUED i (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. ! rrf� r Job AddressC;q&z)iP Q� City Lot Size PM - "- Owner's Name Address Phone ConEracforj�,�: Address Li ense No. Z Phone � C TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ ` .�T PUMP INSTALLATION 1K 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well"Excavation Dia. of Well Casing . Domestic/Private ❑ Gravel Pack ❑ TracyeType of Casing Specifications F1 Public f 1 Other 1.1 Delta u Depth of Grout Seal Type of Grout YP _. I I Irrigation —..Approx. Depth I } Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump . ,— H•P._IfL1.9 State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50'} s t Depth Filler Material (Below 501 - o TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is r r ,*, !lj available within 200 feet.I Installation will serve: Residence_ Commercial— Other , Number of Erving units: "" Number of bedrooms " Character of soil to a depth of 3 feet: Water tattle depth SEPTIC TANK ❑ Type/Mfg Capacity � No. Compartments 1 PKG. TREATMENT PLT. ❑ may' Method of Disposal _ S : TA Distance to nearest: Well Foundation's Property Line LEACHING LINE ❑ No. & Length of lines Total lengt rf FILTER BED ❑ Distance to nearest: Well • Foundation Pro erty Line ' s \ SEEPAGE PITS i 1 DepthSize _ Number SUMPS CI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 4 ENVIRONMEN TAL HEALTH I hereby certify that I have prepared this application and that the work will be done in accordance with SaMIMA4 rdmances, 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 certifi6gthe following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's com I taws of California." pensa- Th`e applicant must call or all required"'nspections. Complete drawing on reverse side. . r Signed X f Title: .�,[.�.. _. _ Date: r D TMENT USE ONLY Application Accepted byi Date 7` Area 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. Box 2009, Silk., CA 95201 Y 1 { FEE AMOUNT DUE AMOUNT REMITTED CK INFO CASH„ RECEIVED BY DATE PERMIYNO. aEH13,24fREV.1/AW 35'� �, EH 14-26 Ct`_` r