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f APPLICATION FOR PERMIT ` " SAN JOAQUIN LOCAL HEALTH DISTRICT p 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 , PERMIT EXPIRES 1 YEAR FROM DATE ISSUED .� €,'(Complete in Triplicate) f" 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. r-, e Job Address ' 'City Lot Size f a PM &av Owner's Name.. Address T Phone Contractor W Address t f License No-DIZ Phon TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ { PUMP INSTALLATION 9 SYSTEM REFAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES tfV DISPOSAL FLO, PROP. LiNE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI NS ❑ Industrial ❑ Open Bottom anteca Dia. of Well Excavatjgn Dia. of Well Casing j Domestic/Private �Gravel Pack ❑ Tracy Type of Casing I! Specifications ❑ Public ❑ O#her ❑ Delta Depth of Grout Seal � Type of Grout ❑ Irrigation 1�Jgpprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ "Well Diameter _.- Sealing Material ftop 501 Depth Filler Material (Below 501 TYPE SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system • permitted if public sewer is k { Installation wr rve: Residence._ Commercial— Other available within 200 feet.) Number of living units: Number of bedrooms Character of soil to a depth of 3 Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ T Method of Disposal Distance to nearest: Well undation Property Line LEACHING LiNE ❑ No. & Length of lines tal length/size FILTER BED ❑ Distance to'nearest: Well Foundation arty Line SEEPAGE PITS ❑ Depth Size Number SUMPS - ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, staaws, 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 thispermit 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 I 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 m W301i for all requir d spections. Complete drawing on rgprerse side. Signed ` /// 1 t Title: Date:/ FOR DEPARTMENT USE ONLY �] Appl1catr!n,Acf opted by Date Pit orro nspecti Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 359-3621 ❑ Manteca 823-7104 ❑ Tracy 835MM Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 E . FEE AMOUNTDUE. AMOUNT REMITTED INFO CLASH RECEIVED BY DATE PERMIT'NO," + EH 13-24{REV-7/85) EH 1le-94 426