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APPLICATION,,f0R PERMIT NID I Som" OAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 (�_ PERMIT EXPIRES TYEAR FROM DATE ISSUED bib C � (Complete in Triplicate) �zL, Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This applic ions 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.'} c 'Xb Address ! �-QN City J Lot Size PM wrier Is Name �AI&P�ress�� hon [ t 1<7 Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ __ _OTHER E)DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES -DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WEL ice_ OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA STRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tfa Type of Casing Specifications I.1 Public ❑ Other ❑ elta Depth of Grout Seal Type of Grout I I Irrigation �_.Approx. Depth i I Eastern Surface Seat Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 501. ^ TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION I I DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.] Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth k SEPTIC.TANK. ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line r LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line d SEEPAGE PITS i I Depth Size Number + SUMPS 1-1 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 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."Contractors 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 applicant tnust call Torreq red inspections. Complete drawing on reverse side. `� 1 Signed X ^ Title: Date: l F MENT USE ONLY Application Accepted by __ � 0 �1L WN - Date O' Area ® t Pit or Grout Inspection by Date_ __ Final Inspection by Date Additional Comments: P-9 7— ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 -/ Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Silk., CA 95201 7� I FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. + EH 13-241REV.k/n5) � eo 1D-2 EH 14-29