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F APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1 1601 E. HAZEI_TON AVE., STOCKTON, CA Telephone (209) 466-6781 I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1 (Complete in Triplicate) I 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. � f/�/ P Size Job Address 1 1 City i Owner's-Name ss Phone ` License No. Phon i Contractor's Name ,TYPE OF WELL/PUMP: NEW WELL Z;,� WELL REPLACEMENT ❑ DESTRUCTION ❑ t a� � ,PUMP INSTALLATION �� SYSTEM REPAIR ❑ OTHER ❑ k 0(j drd PROP. LINE DISTANCE TO'NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.,� FOUNDATION,-�� AGRICULTURE WELL OTHER WELL PITS/SUMPS !V INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial pen Bottom ❑ Manteca -—-Via. o'#Well Excavation Dia. of Well Casing ti Specifications omestic/Private ❑ Gravel Pack- LJ Tracy Type-of Casing f„ ❑ Public} ❑ Other �`* ❑ Delta Depth of Grout Seal �Typrout [I Irrigation --Approx. Depth L) astern, Sur e Seal InstaNed'by Repair Work Done ❑ Type of Pump State Work-Done Well Destruction [],,_.Well Diameter Sea#g Material Itop 50'1 i y t Depth Filler Material l9elow 501 `TYPE OF SEPTIC WORK: NEW INSTALLATION ElREPAIR/ADDITION ❑ 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 `+ , i • aracter of soil to a depth of,'3)feet: Water table depth /,'SEPTIC TANK O Type/Mfg �' �-"""'" "" Capacity No. Compartments I PKG. TREATMENT PLT. ❑ ,` � aa'. ^'' Method•of_Disposal �.� Distance to nearest: 1IVe11' Foundation Property Line ✓`LEACHING LINE ❑ No. & Length of lines Total length/size - ` FILTER BED 1❑ Distance to nearest: Well.---' Foundation Property Line SEEPAGE PITS ❑ Depth Size' Number SUMPS ❑ Distance to nearest: Welr" Foundation Property Line i � �,�pISPOSAL PONDS ❑ - '-�- •------ I hereby certify that I have prepared this application and-fhat the work will be done in accordance with San Joaquin c&iiby'wrlinences, 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." 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 mu II all required inspections. Comp rawing on reverse side. Signed Title: Date: r F EPARTMENT USE ONLY 1 F 'U Date r -SArea Application Accepted by Pit or Grout Inspection by Date Final Inspection by Aatez Additional Comments: 6 k -'?E&(05_ ` ❑ 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, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. INFO iL EH 13-24{REV.10183) �. r`247i T— k�EH 7426