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APPLICATION FOR PERMIT ~ SAN JOAQUIN LOCAL HEALTH DISTRICT F ; 1601 E. HAZELTON AVE., STOCKTON, CA i Telephone (209) 466-6781 ! PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i#F (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. p� Q s7 ♦ Job Address ► �J Gig s r - _ _ City �- Lot Size /� ` M i k Owner's Name ddress / Phone Contractor / v 4' ddress cense No. Phone 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 I 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 ITl Public ❑ Other Ll Delta Depth of Grout Seal Type of Grout i I Irrigation —.-Approx. Depth i-I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H,P. State Work Done Well Destruction ❑ Well Diameter Sealing Material atop 50') Depth l Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION i-I REPAIR/ADDITION l I DESTRUCTION' [No soptic,system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_. Commercial Other Number of living units: Number of rooms Character of soil to a depth of 3 feet: �Water table depth SEPTIC TANK ❑ TypelMfg Capacity _ N(;. C mo partments �f PKG. TREATMENT PLT.. ❑ - ,` Method of Disposal L` Distance to nearest: Well Foundation Property Line � I , f• LEACHING LINE ❑ No. & Length of lines ' Total length/size FILTER BED EJDistance to nearest: Well Foundation Property Line I f SEEPAGE PITS Depth', 0_-.Size _ Number SUMPS Ll Distance to'nearest: Well Foundation Property Line ' DISPOSAL PONDS ❑ I _ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin count—y—drdiaances, state laws, and rules and regulations of the San Joaquin Local Health Dihtrict. _ Home owner or licensed agent's signature[certifles�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 Calif The applicant m call for all required inspections. Complete rowing on re erso side. Signed X itle: Data: _/ A/ O FOR DEPARTMENT USE ONLY Application Accepted by Date Area lf 7 Pit or Grout Inspection Date Final Inspections by 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 CK 41 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMITNO. + EH 13-24[REV.1in5) I f 4 111 —)7 � � ?p1 EH to-?a o BC L