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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON,-CA Telephone (209) 466-6781 € PERMIT EXPIRES 1 YEAR FROM DATE ISSUED F My (Complete in.7ripllcate)31 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. ,C. City� `Lo Job Address t SizeZ00 PM " " u" 4C'' �`.tC.:. Owner's Name Addresg Phone Contractor #Address :License No. Phone I TYPE OF WELL/PUMP: NEW WELL ❑ f WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 0 SYSTEM REPAIR.F OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK i,� SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION # AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL! PROBLEM AREA CONSTRUCTION SPECIFICATIONS 11Industrial LlOpen Bottom 1-1Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy: Type of Casing Specifications r-4 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout �* ❑ Irrigation ---Approx. Depth ❑ Eastern !Surface.Seal Installed by Repair Work Done, ❑ Type of Pump f H.P. State Work Done Well Destruction ❑ Well Diameter w Sealing Material (top 50') T Depth tFiller Material (BeioW 50') i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ -DESTRUCTION (No septic system permitted if public sewer is i available within 20.0 feet.] F s Installation will serve: Residence_ Commercial Other R" 4 f4F Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth � - �— SEPTIC TANK ❑ Type/Mfg t" Capacity-- No. Compartments PKG. TREATMENT PIT. ❑ •'� -- ;w . '� Method of Disposal y Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ -No. & Lengthlof lines Total length/size I FILTER BED El Distance to nearest: Well Foundation Property Line ~ SEEPAGE PITS" ❑ ' Depth SizeNumber v c � SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ElI A 'VP- hereby certify that I have prepared this app/€cation and that the work will be done in accordance with San Joaquin county ordinances, state laws, and t f 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 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." ' a The applicantst call for all required inspections. Complete drawing on reverse side. i; Signed I, Title: �h �� Date:. FOR NT USE ONLY " y Application Accepted by Date ` a Q� z Pitor Grout Inspection by s D to Final Ins ecfair- o r, by {I Date 1 Additional Comments. V Stk 466-Ml ❑ Lodi 369-3621 if C1Manteca ❑ Tracy 835 6385 pp ant Return all copies to: Environmental Health Permit/Semi 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 IFEE NFO AMOUNT DUE �i AMOUNT REMI ED CAH RECEIVED BY DATE PER MIT`NO. 4, Me* bff� + EH 13-24(REV.s/e 51 t.� y � � 1 � �.� �`1 / ' ' EH W26 i ..