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APPLICATION FOR PERMIT SAN JOAQUIN -LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE.,,STOCKTON, CA " Telephone (209) 466-6781 f PERMIT EXPIRES''/ YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the SanJoaquin 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 welllpump and the Rules and Regulations of the San Joaquin Local Health District. f 0 � # ' J PM Job Address Q City Lot Sizd Phone i Owner's Name ,o Address _ Contractor ! N Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ` PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE f FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS k INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS l ❑ Industrial 11 Ll Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic Private M Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ irrigation _. Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work'Done ElType of Pump H.P. State Work Done \\ Well Destruction C1Well Diameter Sealing Material )top 501 Depth I Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (Nailabptiwithin 2permitted rmi ted if public sewer is Installation,will serve: Residence Commercial_ Other Number oflivingunits: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments7, _4 PKG. TREATMENT PLT. ❑ Method of DisposDistance to nearest: Well Foundation Property Line ti I 'LEACHING LINE ❑ No. & Length of lines Total length/size 1 € : FILT9k'BED ❑ Distance to nearest: Well Foundation Property Line r SEEPAGE PITS � a-1Depth} Size Number SUMPS 8 D Distance to newest:. . Well - Foundation Property Line DISPOSAL PONDS ❑ �' T` 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 Locat-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-compensatiori'Iaws of California."Contractor's hiring or subcontracting signature certifies the following:"I certify that in the performance of the work`ffor,which this permit is issued,I shall employ,persons subject to workman's compensa- tion laws of California." ' y'�' �' The applicant must call for all required inspections. Complete drawing an reverse side. p ` 1 Signed X� fl Title:. F i Date:/Z�!d FOR DEPARTMENT USE ONLY I r AC Application Accepted by Data Area Rate Final Inspection by Date i Pit or Grout Inspection by v A itional Comments: tk 466-6781 ❑ Lodi 369-311121 I© Manteca 823-7104 s, © Tracy�835-6385 _/ App cant- Return-all-copies to,.-Environmental-Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 209941C, C 5201 a..t is 'L� _ ✓—cr IFEE NFO AMOUNT DUEe AMOUNT REMITTED C RECEIVED BY DATE PERMIT'NO. '+ EH 13-24 4REV.5 i e 5Y EH 14-28- _ - -- 6