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APPLICATION.FOR PERMIT I--evSAN JOAQIUIN LOCAL HEALTH DISTRICT fUR`�1 1601 E. HAZELTON AVE., STOCKTON C ""- r A PTelephone (209) 466_6781 1 ERMIT 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 i made H compliance with San Joaquin County Ordinance No.549 for sewage or No. 7.862 for well/Pum an Loco! Health District. �"- "� hereiri described. This application is -„ - . 4,c p d the Rules'arid Regulations of the San Joaquin Job Address 10 (t0._.- lr > f,. City y..:n Owner's Name�� - Lot Size PM r Address � r Contra,+_. Address TYPE OF WELL/PUMP: fi NEW WELL ❑ License No Phone F3 # PUMP INSTALLATION WELL REPLACEMENT ❑ DISTANCE TO NEAREST: SEPTIC TANK SYSTEM REPAIR ❑ DESTRUCTION F) SEWER LINES OTHEA Ll DISPOSAL FLD. PROP. LINE # INTENDED USE ~ TURE WELL OTHER WE TYPE OF WELL PROBLEM AREA CO LL S ❑ Industria! ❑ Open Bottom TIONS ❑ Domestic/Private ❑ Man' t� Dia. of.Well Excavation ~ ❑ Gravel Pack racy T is. of Well Casing ❑ Public ED Other �a Type of Casing ❑ Irrigation ( ❑ Delta`` 'y'.v. 5� Depth of Grout Seal Specifics �Approx. Depth EDEastern Type of Grout Repair Work Do Surface Sea! Installed by TYPe of Pump 1 H.P. Well Des ction ❑ Well Diameter -;� State Work Done \ Sealing Material (top 50') Depth TYPE OF SFiller Material (Below 50'] /r EPTIC WORK: NEW INSTALLATION ❑ .REPAIR/ADDITION ❑ DESTRUCTIONS (No septic system permitted if public sewer is Installation will serve: ResidenceCommerciaOther available within 200 feet.) l . Number of living units: Number of bedrooms �r Character of soil to a depth of 3 feet: 1 SEPTIC TANKType/Mfg ' ' ' -- - Water table depth PKG. TREATMENT PLT. ❑ "' Capacity.,;l No: Compartments Distance to nearest: 1 Method of Disposal Well Foundation t Property Line LEACHING LINE EV No. &Length of lines FILTER BED ' Total length/size ❑- Distance to nearest: Well ' i Foundation Property Line SEEPAGE PITS ❑ Depth '' -t' Size Number SUMPS ❑ Distance to nearest: Well DISPOSAL PONDS ❑ + Foundation Property Line 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 Local Health District.- employnowner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this Y person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature ; certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall employ permit is issued, I shall not tion laws of California." P y persons subject to workman's compensa- tion ap licant must call forll q 'red inspectia . Complete drawing on reverse side. '" Signed Yt '�. _ Title: Date: FOR DEPARTMENT USE ONLY r� , ` Application Accepted _ Date 01A Area Pit or Grout Inspection Date Final Inspection by Date 0 .Additional Comments: ' s �/ - Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-71040 �f D Tracy 835-6385 `sant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 a J ,t - i F ' FEE FO AMOUNT DUE AMOUNT REMITTED K SH RECEIVED BY DATE PERMIT-NO.