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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Y San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the R41es and Regulations of the San Joaquin Application is hereby made to the San Joaquin Local Health District for a permit to construct andlor install the work herein described.This application 3s made in compliance with q Local Health District, f City � Lot Size PM Job Address PhonZ F tG ��C�-� Addre Owner`s Name / Contractor �f� C Address License No J 2j -Phone f TYPE OF WELL/PUMP: NEW WELL Ll WELL REPLACEMENT ❑ DESTRUCTION 11 ; SYSTEM REPAIR �❑- OTHER ❑ PUMP INSTALLATION E] �, SEWER LINES = DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK �— PITS/SUMPS FOUNDATION �— AGRICULTURE WELL OTHER WELL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing ❑ Industrial E3Open Bottom j ❑.Manteca Dia. of Well Excavation Specifications domestic/Private ❑-Gravel-Pack -❑ Tracy _---Type,of Casing [I Public Ll Other El Delta Depth of Grout Seal Type of Grout I rox. Dept ❑ Eastern Surface Seal Installed by F-1 Irrigation App r State Work Done Repair Work Done 1� Type of Pump lH_P., , 'Sealin Material (top 50') Well Destruction ❑ Well Diameter g Depth -Filler Material-(Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ a �ilabPe1v+rit Sne200 feetitted if public sewer is Installation will serve: Residence, Commercial Other Number of living units: Number of bedrooms "" f Water table depth Character of soil to a depth of 3 feet: No. Compartments SEPTIC TANK ❑ Type/Mfg Capacity Method of Disposal PKG. TREATMENT PLT. i7 j Property Line Distance to nearest: Well Foundation r , LEACHING LINE 13 No. & Length of lines .`Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line fSize Number SEEPAGE PITS ❑ Depth Property Line SUMPS �, rl❑' Distance to.nearesV- ,,,I Well Foundation _�- DISPOSAL PONDS ❑._--..----•— i that the work will be done in accordance with San Joaquin county ordinances, state laws, and I hereby LPOertify that l have prepared this application and rules and regulations of the San Joaquin Local Health District. f 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: 11 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 ca for all re ed inspections. Complete drawing o, revers side. 41 Date �� e: : < Signed FOR DEPARTMENT USE ONLY Date � !� Area Application Accepted by t Pit or Grout Inspection by Date Final Inspection by Date i Additional Comments: f ❑ Stk 466781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 k Applicant Return all copies to: Environmental Health Permit/Services 1801 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE CK RECEIVED BY DATE PERMIT NO. INFO AMOUNT DUE AMOUNT REMITTED CASH s=/ � +EH 13.24fREV.t/85> r7 1,0 � EH 14-26