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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES I 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address r ! 1 y' 4) -D City OQtf Size PM Owner's Name Address Phone TYPE OF WELL/PUMP: NEW WELL ❑ PUMP INSTALLATION ❑ DISTANCE TO NEAREST: SEPTIC TANK FOUNDATION WELL REPLACEMENT ❑ DESTRUCTION ❑ SYSTEM REPAIR ❑ OTHER ❑. SEWER LINES DISPOSAL FLD. PROP. LINE 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 ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other I. ❑ Delta Depth of Grout Seal Type of Grout_ ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H. P. .f - State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Z, Water table depth Depth k Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION STRUCTION ❑ (No septic system permitted if public sewer is AMOUNT REMITTED CASH RECEIVED BY DATE available within 200 feet.) Installation will serve: Residence i 1 Commercial _. Other. 301 Number of living units:_ Number of bedrooms T j Character of soil to a depth -of 3 feet ' Water table depth SEPTIC TANK ❑ Type/Mfg ' Capacity_! -No. Compartments PKG. TREATMENT PLT. ❑ Distance to l^^ )�o - Method of Disposal nearest: Well Foundation SSL Property Line LEACHING LINE. & Length of lines Is a t Total length/size FILTER BED ❑ Distance to nearest: Well t Foundation Property Line SEEPAGE PITS SC} Deipth i Size Number �. SUMPS_ ElDistance to nearest: Well Foundation- Property Line DISPOSAL PONDS ❑ ) s 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 aapp ust call all requir Inspec ' ns. G Tete drawing on reverse side. Sig Title. Data: C;) --,F FOR DEPARTMENT USE ONLY Application Accepted by Date Z' Q+ Area p.aa A�,... It pp Pit or Grout Inspection byerten Date —1-fi-Jhl Final Inspection by 1>u Date Additional Comments: r ❑ Stk 466-fi781 ❑ 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 f + EH 1324 (REV. 10/83 EH 1426 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`NO. 1 � �s 301