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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 .1PERMIT 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 r made in compliance with San Joaquin County Ordinance No.549 for sewage of No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 5 n� H _� City Lot Size PM Owner's Name Address /�ej�r'-,(/`is _ Phone Zq1 B w1� m� License No. Phone Contfactor" Address TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION D PUMP INSTAL'.LATION ❑ SYSTEM REPAIR ❑ OTHER ❑! DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP- LINE FOUNDATION_ 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 r t — ❑ Domestic/Private i ❑ Gravel Pack ❑ Tracy Type of Casing > Specifications F1 Public } Cl Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation t �_Approx."Depth I ! Eastern Surface Seal Installed by f r f Repair Work Done ❑ Type of Pump H.P. State Work Done.w�. Well Destruction ❑ Well Diameter Sealing Material itop 50'f Depth Filler IBelow 50'1 — ` TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAI /ADDITIO DESTRUCTION11'1 ANo septic sysiem permitted if public sewer is available within 200 feet. ) z installation will serve: Residence . Commercial— Other_� , Number of living units: Number of bedrooms-- r `' Character of soil io a depth of 3 feet: Water table depth+ SEPTIC TANK 1 171Type/Mfg Capacity.f. No. Compartments PKG. TREATMENT,PLT. ❑ ` t Method af"Disposal # --.',�`Disfance to nearest: Well Foundation Property Line ... f 41f th of li} t LEACHING LINE � � No. &Lengnes � � Total length/size j� FILTER BED ❑ Distance to nearest:- Well Foundation Property Line �%— ` i\ r:J ..:L r SEEPAGE PITS I1 Depth Size X Npbef SUMPS l Distance to nearest: Well " Foundation O Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared thispa plication and that the work will tie done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local.Health Di3trict. not 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 ure employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature workman's com ansa- „ II employ arsons subject to p certifies the folio g: I certify that rn the,performance of the work for which this permit is issued, I sha p y p J 't tion laws o4 Cali 6 The applic st call f all re u'ed in`spec" C plete;drawing on reverse side Signed ti Title: FOR DEPARTMENT USE ONLY �1 } Application Accepted by Date4 ��~ Area Pit or Grout Inspection by Date Final Inspection by Data 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, Sik., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO ,.Eli 13-741REV.1/H51 '-EH 14-2e