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APPLICATION FOR PERMIT JL SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEIrTON AVE., STOCKTON, CA Telephone (209) 466-6781 �O�g`� ,��► } f PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . (Complete in Triplicate) I Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work erein application is ce No.549 for sewage or No. 1862 for well/ and the Rules and`R�ea the San Joaquin made in compliance with San Joaquin County Ordinan k Local Health District ry � ZO �a. city Y� Lot Size PM Job Address f Address /`'L /�/J z �. C hone Owner's Name f Contractor L raJ' Address ZS r License No_ done 5 TYPE OF WELL/PUMP: NEW WELL C5WELL REPLACEMENT)8LDESTRUCTION ❑ PUMP INSTALLATION /❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL t 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 I)e Gravel Pack Tracy" Type of Casing 10�G Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ElWell Diameter Sealing Material Itop 501 Depth"I Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW,INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet./ 4 C Installation will serve: Residence_ Commercial - Other A Number of living units: 1.1 Number of bedrooms R I t Character of soil to a depth of"3 feet: Water table depth Ca act No. Compartments SEPTIC TANK ❑ Type/Mfg Capacity_ j PKG. TREATMENT PLT. ❑ ! Method of Disposal Distance to nearest: Well Fou ion Property Line LEACHING LINE ❑ 0& Length of.lines Total length/size FILTER BED ❑ Distance to nearest: Wel Foundation Property Line E ;1 SEEPAGE PITS ❑ Depth Size Number s 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 employ any person in such manner as to become subject to workman's compensation laws of Califomia."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 applicantrrpst call for all require 'nspections. Complete drawing o reverse s,i4e. Signed Title: Date: —Z1-8 ` R DEPARTMENT USE ONLY Application Accepted by Date "�" Are Pit r Grout nspection by Date .� Final Inspection by Date t� Additional Comments: ❑ Silk 456-6781 [1 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835- 6385 Applicant- Return alt copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVEt)BY DATE PER;1 NO, INFO010 ' 70°O -70 - EH 1428