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f APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 r. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) r 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. -, , : ►{ f Y u Job Address 1} City IA Size PM 'k l loV'� Phone Owner's Name Contractor's Name :It Z— License No. Phone �J TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR © OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS , ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing &'Domestic/Private ElGravel Pack' LJ LJTracy Type of Casing Specifications ❑ Public ❑ Other A ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done LI Type of Pump, -t H.P. State Work Done in Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 lIJ Depth Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION`❑ DESTRUCTION ❑ Mo septic system permitted if public sewer is f available within 200 feet.l Installation will serve: Residence J Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:i Water table depth SEPTIC TANK ❑ Type/Mfg 1 Capacity No. Compartments PKG. TREATMENT PLT. ❑ 11 Method-of Disposal p Distance to nearest: Well Foundation Property.Line T, LEACHING LINE ❑ No. & Len6th of lines Total length/size FILTER BED ❑ Distance I nearest: r Well Foundation Property Line i SEEPAGE PITS ❑ Depth 3 Size Number „SUMPS ❑_ :Distance to nearest: Well Foundation Property Line - DISPOSAL PONDS ❑ I r _ _ 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 E employ any person in such manner as,to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature I certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall employ pe t to wow en's compensa r tion laws of California." > ry. The applicant call for all required inspecti s. Complete drawing on reverse side. / J?&A ' Signed - �Title:_ ate: Of FOR EPARTMENT USE ONLY c Date iJ .-�� ,era --t ty ©Cs Application Accepted by �` `r 7 �J Pit or Grout Inspection by Dat Final Inspection b i Additional Comments: I ❑ Stk 466-6761 ❑ 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 IFEE NFO AMOUNT DUE: AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`NO.' + EH 13-24[REV.101831 �! e/4/ S AZy u EH 1428 }dl �' -